% 


'"hi-       >ok  •■-   PVt  oTi  the  last  date  stamped  below 


WT*  A  'VV 


STAT 


RUSSELL    SAGE 
FOUNDATION 


MEDICAL   INSPEC- 
TION OF  SCHOOLS 

ByLUTHERHALSEYGULICK.M.D. 

DIRECTOR    OF   PHYSICAL  TRAINING,  NEW  YORK 
PUBLIC  SCHOOLS 

AND 

LEONARD   P.  AYRES 

GENERAL    S  U  P  E  R  !  N  T  E  SI  D  E  N  f   OF 
SCHOOLS  OF   PORTO   RICO,   I906-I908 


I  e  '-3  J 


NEW    YORK 

CHARITIES    PUBLICATION 

COMMITTEE 

MCMVIII 


^^?^r.  1^09 


Copyright,  1908,  by 
The  Russell  Sage  Foxtndation 


PKESS    Of 
WM.     r.     FELL    COMPANY 

rniLADELrniA 


Contents 


/ 


Introduction 

PAGE 

Significant  Facts i 

CHAPTER  I 

Nature  and  Aims  of  Medical  Inspection 

Protection  of  the  community 5 

Development  of  the  individual 5 

Our  change  from  rural  to  urban  life 6 

(f     Population  of  foreign  parentage  in  American  cities 7 

Changed  conditions  of  work 8 

Changed  conditions  of  play 9 

CHAPTER  II 

The  Argument  for  Medical  Inspection 

The  attitude  of  educators  towards  the  physical  well-being  of  children        .        .12 

The  "lockstep"  in  physical  matters 13 

^    Awakening  interest  in  problems  of  backward  children 14 

Physical  defects  and  school  life 15 

Medical  inspection  does  not  entail  trespass  on  personal  liberty  .        .        .        .16 

CHAPTER  III 

Historical 

Rise  of  medical  inspection  in  France 18 

•Rise  of  medical  inspection  in  Belgium  and  Germany 19 

The  Wiesbaden  plan 19 

Hungary,  Austria,  and  Norway 20 

Sweden,  Roumania,  Moscow,  and  Switzerland 21 

•The  English  Medical  Inspection  Act 21 

La  Medecine  Scolaire         ...                22 

^         Chile,  Argentine  Republic,  and  Japan 23 

\    •»New  York  City 24 

\»State  Laws  of  Connecticut,  New  Jersey,  Vermont,  and  Massachusetts       .        .  25 

•Cities  of  the  United  States  having  medical  inspection 26 

CHAPTER  IV 

Inspection  for  Detection  of  Contagious  Diseases 

Exclusion  cards , 29 

^      Medical  inspection  in  New  York  City      .        .        .        .      • 30 

iii 


iv  Contents 

PAGE 

Forms  used  in  Providence,  R.  1 40 

A  system  of  records  for  medical  inspectors 41 

Combined  directions  and  prescriptions 46 

Contagious  diseases  for  which  pupils  are  excluded 48 

Beneficial  results  of  medical  inspection 50 

CHAPTER  V 
The  Work  of  the  Teacher  in  Detecting  Contagious  Diseases 

(Competence  of  teacher  to  detect  symptoms  of  disease 52 

Directions  for  referring  pupils  to  school  physician  ......  55 

Hygiene  rules  for  pupils 57 

Forms  used  by  teacher  to  refer  pupils  to  school  physician 59 

CHAPTER  VI  i^ 

The  School  Nurse 

Opinions  on  the  value  of  school  nurses 66 

The  work  of  school  nurses  in  New  York  City 67 

The  work  of  school  nurses  in  Philadelphia 69 

The  work  of  school  nurses  in  Boston 73 

Forms  used  in  connection  with  work  of  nurses 77 

CHAPTER  VII 

Physical  Examinations  for  the  Detection  of  Non-Contagious  Defects 

The  basis  of  the  argument  for  conducting  physical  examinations        .        .        .     82 

Results  of  vision  and  hearing  tests  in  public  schools 83 

Physical  examinations  in  New  York  City 86 

•"      Application  of  work  of  school  physician  to  work  of  class  room    .        .        .        .89 

Forms  used  in  connection  with  physical  examinations 94 

Directions  concerning  the  care  of  the  teeth 98 

Extent  to  which  defects  discovered  are  remedied 10 1 

CHAPTER  VIII  i: 

Vision  and  Hearing  Tests  by  Teachers 

"        Ability  of  teachers  to  conduct  vision  and  hearing  tests 104 

Sight  and  hearing  tests  in  Massachusetts 107 

Eye  and  ear  examinations  by  New  York  State  Department  of  Health        .        -113 
Eyesight  tests  conducted  by  State  Board  of  Education  of  Connecticut       .        .  120" 
Examinations  of  the  State  Board  of  Health  of  Utah 129 

CHAPTER  IX    .^ 

Administration 

Four  classes  of  systems  of  medical  inspection 137 

Salaries  of  medical  inspectors  and  number  of  pupils  per  inspector.     .        .        -139 

Salaries  of  school  physicians  in  England 142 

Salaries  of  nurses i44 

Salaries  of  medical  inspectors  in  Germany i44 

The  question  of  free  eyeglasses 148 


Contents  v 

CHAPTER  X 

Controlling  Althorities 

PAGE 

Board  of  Health  or  Board  of  Education 150 

Detection  of  contagious  disease  a  function  of  tlie  Board  of  Health      .        .        .158 
Development  of  the  individual  a  problem  for  the  Board  of  Education        .        .158 

CHAPTER  XI 

Legal  Aspects  of  Medical  Inspection 

The  English  law iS9 

The  Massachusetts  act 162 

The  New  York  law  concerning  children  in  public  institutions     .        .        .        .166 

The  New  Jersey  statute 171 

The  Connecticut  law 176 

The  Vermont  law 181 

CHAPTER  XII 

Retardation  and  Ph^'sical  Defects 

Medical  inspection  and  financial  economics 185 

Retardation  and  part  time 186 

Class  standing  of  children  and  physical  defects 189 

Causes  of  backwardness 190 

Physical  defects  and  age  in  grade 192 

Decrease  of  defects  with  age 199 

BIBILIOGRAPHY 

APPENDIX  I 

"Suggestions  to  Teachers  and  School  Physicians  regarding  Medical  Inspec- 
tion," issued  by  the  Massachusetts  Board  of  Education      ...        .  232 

APPENDIX  II 
A  typical  set  of  European  blanks  and  forms  (those  used  in  Briinn,  Austria)     .  238 

APPENDIX  III 

Rules  issued  to  medical  inspectors  of  schools  in  Chicago,  111.;  Detroit,  Mich.; 

and  Springfield,  Mass 251 

INDEX 


vi  Contents 


Charts 

PACE 

1.  Teeth  chart,  Northampton,  Mass 97 

2.  Snellen's  chart  for  testing  eyesight,  Massachusetts iii 

3.  Chart  of  letters  for  testing  eyesight,  Connecticut 122 

4.  Chart  for  testing  focusing  power,  Connecticut 123 

5.  Chart  of  graduated  figures,  Connecticut 124 

6.  Chart  of  E's,  Connecticut 125 


Forms 

PACE 

1.  Exclusion  card,  Brockton,  Mass 30 

2.  Monthly  report  of  medical  inspector,  Brockton,  Mass 31 

3.  Postal  card  notice  to  principal,  New  York  City 34 

4.  Exclusion  card,  New  York  City 35 

5.  Code  card.  New  York  City 36 

6.  Index  card.  New  York  City 37 

7.  Inspector's  daily  report  of  exclusions,  New  York  City 38 

8.  Inspector's  daily  report  of  exclusions;  reverse;  New  York  City     .        .        .  39 

9.  PLxclusion  notice,  Chicago 42 

10.  Envelope  daily  report  of  medical  inspection,  Chicago 43 

11.  Combined  directions  and  prescription,  Everett,  Mass 44 

12.  Combined  directions  and  prescription,  Everett,  Mass 45 

13.  Rules  for  contagious  diseases.  Providence,  R.  1 56 

14.  Printed  rules  distributed  to  pupils,  Providence,  R.  1 57 

15.  Teacher's  request  to  inspector.  Providence,  R.  1 59 

16.  Card  of  request  to  inspector,  Asbury  Park,  N.  J 59 

17.  Request  of  teacher  and  statement  by  inspector,  Washington,  D.  C.     .        .     60 

18.  Duplicate  of  above 61 

19.  Statements  of  physician  and  teacher,  Somerville,  Mass.         .        .        .        .62 

20.  Card  used  by  Dr.  Newmayer  in  Philadelphia 63 

21.  Slip  taken  by  pupils  to  inspector,  Philadelphia 64 

22.  Card  recommending  pupil  for  treatment,  Philadelphia 77 

23.  Weekly  report  of  nurse,  Philadelphia 78 

24.  Weekly  report  of  nurse,  Baltimore 79 

25.  Individual  record  card,  New  York  City 84 

26.  Postal  card  notice  to  parents.  New  York  City 86 

27.  Reverse  of  above  card 86 

28.  Record  card  showing  teacher's  comments,  Pasadena,  Cal 90 

29.  Reverse  of  above  card 91 

30.  Physical  record  card,  Los  Angeles,  Cal 92 

31.  Reverse  of  above  card 93 

32.  Physical  record  card,  Utica,  N.  Y 94 

33.  Physical  record  card,  Asbury  Park,  N.  J 95 

34.  Notification  to  parents,  Somerville,  Mass 96 

35.  Notification  to  parents,  Ann  Arbor,  Mich 96 

36.  Report  on  eyesight  and  hearing  tests  to  superintendent,  Massachusetts      .  no 

37.  Record  of  sight  and  hearing  tests,  Massachusetts 112 

38.  Notice  to  parents  or  guardian  by  teacher,  Massachusetts      .        .        .        -113 

39.  Notice  to  parents  or  guardian  by  school  physician,  Massachusetts       .        -113 

40.  Report  of  teacher,  New  York  State iiS 


Contents  vii 

PAGE 

41.  Report  of  teacher,  New  York  State 119 

42.  Notice  to  parents,  New  York  State 120 

43.  Teacher's  report  to  parent  or  guardian,  Connecticut 127 

44.  Teacher's  report  to  State  Board  of  Education  of  Connecticut       .        .        .128 

45.  Report  to  State  Board  of  Education  of  Connecticut 128 

46.  Card  of  warning  to  parents,  Utah 130 

47.  Report  by  teacher,  Utah 131 

48.  Report  to  State  Board  of  Health,  Utah 132 

49.  Teacher's  report  to  principal,  Ogden,  Utah 133 

50.  Blank  for  excuse  for  absence,  Ogden,  Utah 134 

APPENDIX   II 
(Forms  used  in  Briinn,  Austria.) 

51.  Notice  to  parents 238 

52.  Notice  to  parents 239 

53.  Health  report 240 

54.  Reverse  of  above  report 241 

55.  Monthly  and  yearly  report  of  findings 242 

56.  Monthly  and  yearly  report  of  visits  by  school  physicians       ....  243 

57.  Physician's  report 244 

58.  Memorandum  blank  of  unhygienic  conditions  in  school-houses    .        .        .  244 

59.  Questions  to  parents  or  guardians 245 

60.  Individual  health  report 246 

61.  Reverse  of  above  form 247 

62.  Notice  to  parents,  dental 248 

63.  Reverse  of  above  form 349 

64.  Notice  to  dentist 250 


Tables 

PAGE 

1.  Table  showing  population  of  foreign  parentage  in  various  American  cities       7 

2.  Table  showing  cities  of  the  United  States  having  some  form  of  medical 

inspection 26 

3.  Contagious  diseases  for  which  pupils  are  excluded  in  five  cities    .        .        .48 

4.  Examinations  and  exclusions  in  five  cities 49 

5.  Diseases  and  defects  reported  in  Massachusetts 49 

6.  Exclusions  in  New  York  City  public  schools 68 

7.  Excludable  diseases  in  New  York  City 68 

8.  Table  showing  work  of  trained  nurses,  Philadelphia 70 

9.  Table  showing  nurse's  visits  to  homes,  Philadelphia 71 

10.  Table  showing  results  of  vision  and  hearing  tests 83 

11.  Physical  examinations  in  New  York  City  and  Minneapolis   .        .        .        -87 

12.  Facts  in  regard  to  medical  inspection  in  1 7  cities 140 

13.  Expense  of  medical  inspection,  Springfield,  Massachusetts    ....  146 

14.  Expense  of  medical  inspection,  Montclair,  New  Jersey 146 

15.  Expense  of  medical  inspection.  East  Sussex,  England 147 

16.  Standing  in  studies  of  normal  and  defective  children,  Philadelphia      .        .  189 

17.  Defective  children  rated  "exempt"  and  "non-exempt"  in  Philadelphia     .  189 

18.  Bright  and  dull  children  having  nose  and  throat  defects,  Philadelphia        .  189 

19.  School  standing  of  children  having  normal,  fair,  and  bad  vision,  Phila- 

delphia        190 


Vlll 


Contents 


20. 
21. 
22. 


Reasons  for  excessive  age  of  children,  Camden,  N.  J.    . 

Distribution  of  pupils  by  grades  and  defects,  New  York  City 

Distribution  of  pupils  by  ages  and  defects,  New  York  City   . 

Physically  defective  pupils  by  grades  and  groups.  New  York  City 

Average  number  of  defects  per  child.  New  York  City    . 

Per  cent,  having  each  defect.  New  York  City 

Per  cent,  having  each  defect  by  ages,  New  York  City    . 

Per  cent,  defective  by  defects  and  grades.  New  York  City    . 

Defects  per  100  children  by  grades.  New  York  City 

Defects  per  100  children  by  ages.  New  York  City  . 

30.  Per  cent,  having  each  defect  by  sexes.  New  York  City  . 

31.  Defects  per  child  by  sexes.  New  York  City      .... 


23- 
24. 

25- 

26. 
27. 
28. 
2q 


PAGE 
191 
192 

193 
194 

19s 
195 
197 
197 
198 
199 
199 


Introduction 

S/31 

This  volume  is  one  of  the  by-products  of  the  "  Backward  Children 
Investigation",  a  research  supported  by  the  Russell  Sage  Foundation 
for  the  purpose  of  studying  so-called  "retardation"  among  school 
children.  The  investigation  was  inaugurated  in  November,  1907. 
No  small  part  of  the  study  of  the  adaptability  of  the  school  and  its 
grades  to  children  has  consisted  of  investigation  into  the  effect  of  school 
life  on  the  physical  welfare  of  the  child.  In  the  course  of  this  investiga- 
tion it  has  been  found  necessary  to  accumulate  information  as  to  what 
was  being  done  for  the  health  of  children,  from  both  the  pedagogical 
and  medical  standpoints,  in  the  chief  cities  and  countries  of  the  world. 
The  information  relative  to  medical  inspection  was  so  scattered,  and  the 
desire  for  reliable  information  on  the  topic  so  general,  that  it  was  decided 
that  it  would  be  wise  to  pubHsh  the  available  matter  at  once. 

This  book  aims  primarily  at  results  of  a  practical  natiure.  We  believe 
that  it  contains  material  of  scientific  value,  but  the  form  of  presentation 
is  intended  to  render  it  of  service  to  all  who  are  directly  connected  with, 
or  interested  in,  the  betterment  and  safeguarding  of  the  health  and 
vitality  of  the  future  citizens  of  America. 

The  importance  of  steps  looking  toward  the  health  of  our  public 
school  children  is  indicated  by  the  following  facts: 

1.  The  school  is  the  only  governmental  department  that  directly 
assumes  control  of  children's  lives. 

2.  At  least  nine  out  of  every  ten  of  all  American  children  are  subject 
to  this  control;  and 

3.  Such  control  is  maintained  (roughly  speaking)  during  the  critical 
years  of  from  seven  to  fourteen. 

Because  of  the  practical  nature  of  our  objects,  there  have  been 
included  in  the  bibliography  titles  of  books,  reports,  and  articles  on 


X  Introduction 

medical  inspection,  containing  material  not  relevant,  and  hence  not 
used  or  referred  to,  in  our  particular  study. 

There  seems  to  be  a  general  impression  in  America  that  medical 
inspection  is  still  experimental  and  on  trial,  and  that  we  are  leading 
in  this  important  work.  The  reverse  of  both  of  these  impressions  is 
true.  With  Brussels  having  a  systematic  inspection  since  1874  and 
Paris  since  1884,  scientific  journals  in  France  and  Germany  devoted 
exclusively  to  this  subject,  and  the  movement  a  national  one  in  France, 
England,  Belgium,  Sweden,  Switzerland,  Bulgaria,  Japan,  and  the 
Argentine  Repubhc,  it  is  evident  that,  save  in  details,  the  matter  is  a 
settled  one,  and  that  America  is  one  of  the  last  of  the  civilized  nations 
to  seriously  consider  these  problems. 

This  book  aims,  then, 

1 .  To  be  of  practical  use. 

2.  To  be  a  reliable  source  of  information  as  to  what  is  now 

being  done  and  how  it  is  being  done. 

3.  To  be  frank  in  its  admission  of  problems  and  difficulties 

not  yet  solved,  as  well  as  in  the  portrayal  of  stubborn  ariQ 
hitherto  unsuspected  and  apparently  unreconcilable  facts, 
such  as  are  discussed  in  Chapter  XII. 

4.  To  avoid  all  dogmatism  saving  that  involved  in  the  statement 

of  actual  experience. 

L.  H.  G. 
L.  P.  A. 
New  York,  September,  1908 


Significant  Facts 


Medical  Inspection  "  is  founded  on  a  recognition  of  the  close  connec- 
tion which  exists  between  the  physical  and  mental  condition  of  the  child- 
ren and  the  whole  process  of  education."  It  "  seeks  to  secure  ultimately 
for  every  child,  normal  or  defective,  conditions  of  life  compatible  with 
that  full  and  effective  development  of  its  organic  functions,  its  special 
senses,  and  its  mental  powers,  which  constitute  a  true  education." — {Ex- 
tract from  Memorandum  of  British  Board  of  Education.) 

Medical  Inspection  is  a  movement  national  in  scope  in  England, 
France,  Belgium,  Sweden,  Switzerland,  Bulgaria,  Japan,  the  Argentine 
Republic,  and  practically  so  in  Germany.  In  the  United  States  seventy 
cities  outside  of  Massachusetts,  and  all  the  cities  and  towns  of  that  state, 
have  systems  of  medical  inspection. 

Massachusetts  has  a  compulsory  medical  inspection  law.  New 
Jersey  has  a  permissive  one,  Vermont  a  law  requiring  the  annual  testing 
of  the  vision  and  hearing  of  all  school  children,  and  Connecticut  one 
providing  for  such  tests  triennially. 

As  a  rule,  the  work  of  medical  inspection  is  underpaid  in  America. 
In  England  such  services  are  compensated  at  the  rate  of  from  $1500  to 
$4000  per  annum,  while  in  America  $200  has,  in  many  quarters,  come 
to  be  regarded  as  a  standard  salary  for  the  services  of  the  school  phy- 


Systems  themselves  vary  so  widely  in  scope  and  thoroughness  here 
in  America  as  to  range  in  annual  per  capita  cost  from  half  a  cent  to  a 
dollar  and  twenty-two  cents. 


^ 


2  Medical  Inspection  of  Schools 

Clear  distinction  must  be  made  between  medical  inspection  solely 
for  the  detection  of  communicable  disease  and  that  physical  examination 
which  aims  to  discover  defects,  diseases,  and  physical  condition.  The 
one  relates  primarily  to  the  immediate  protection  of  the  community, 
while  the  other  looks  to  securing  and  maintaining  the  health  and  vitality 
of  the  individual. 

Medical  inspection  for  the  detection  of  contagious  diseases  can  be 
adequately  performed  at  an  annual  cost  of  about  fifteen  cents  per  capita, 
while  physical  examinations  similarly  performed,  and  including  the  in- 
spection for  the  detection  of  communicable  diseases,  cost  about  fifty 
cents. 

Effective  medical  inspection  for  the  detection  of  communicable 
diseases  can  only  be  conducted  by  the  Department  of  Health,  or  at  least 
with  its  active  co-operation,  because  of  the  necessity  for  legal  authority 
for  protecting  the  community,  not  only  during  epidemics  of  contagious 
diseases,  but  also  to  prevent  them. 

Effective  physical  examination  can  only  be  conducted  by  the  Board 
of  Education,  or  at  least  with  its  full  co-operation,  because  it  involves  the 
following  of  the  child  from  grade  to  grade  and  year  to  year.  It  involves 
the  constant  attention  of  the  teacher  with  reference  to  seating  the  deaf 
where  they  can  hear  best,  and  those  having  poor  vision  where  they  can 
see  best,  as  well  as  constant  co-operation  with  the  parents. 

Physical  examinations  can  be  well  made  by  an  experienced  school 
physician  in  from  twelve  to  fifteen  minutes  per  child.  Vision  and  hear- 
ing tests  demand  from  three  to  five  minutes  per  child. 

The  conduct  of  medical  inspection  is  such  a  technical  matter  and  is 
so  different  from  the  work  done  by  the  practising  physician  as  to  demand 
special  training  and  experience. 

Investigations  so  far  indicate  clearly  that  physical  defects  of  children 
decrease  with  age.  That  is,  taking  into  consideration  a  sufficiently 
large  number  of  cases,  children  of  fourteen  years  of  age  show  fewer  de- 
fects than  do  those  of  thirteen  years,  and  these,  in  turn,  fewer  than  those 


Significant    Facts  3 

of  twelve  years.  Hence  older  children  have  fewer  defects  in  whatever 
grades  they  may  be  found,  and  so,  from  the  very  definition  of  the  term, 
retarded  children  in  any  given  grade  have  fewer  defects  than  children 
of  normal  age  in  the  same  grade.  This  fact  is  in  direct  contradiction 
not  only  to  the  prevailing  opinion,  but  also  to  the  conclusions  that  have 
been  emphasized  in  current  professional  discussion  to  the  effect  that 
children  behind  their  grades  were  so  because  of  the  handicap  imposed 
on  them  by  physical  defects.  This  important  fact  should  not  in  any 
way  lessen  our  endeavors  to  bring  the  aid  of  medical  science  to  the  ser- 
vice of  the  physically  handicapped.  It  should  rather  give  us  renewed 
hope,  for  we  find  that  the  direct  tendencies  of  normal  growth  make  to- 
ward rather  than  away  from  those  wholesome  physical  conditions  that 
it  is  the  aim  of  every  physician  and  every  educator  to  bring  about. 

Physical  defects  are  not  equally  significant  either  from  the  medical 
or  from  the  pedagogical  standpoint.  It  is  unfair  and  tends  toward  mis- 
leading conclusions  to  include  in  the  same  classification  pediculosis  and 
defective  vision,  club-foot  and  defective  hearing,  adenoids  and  ring 
worm.  Therefore  the  effects  of  each  kind  of  defect  should  be  separately 
studied — e.g.,  the  effects  of  defective  vision,  hearing,  adenoids,  carious 
teeth,  etc.,  upon  school  progress  and  upon  health. 


CHAPTER  I 

Nature  and  Aims  of  Medical  Inspection 

Two  great  forces  have  been  making  in  America  toward  medical 
inspection  of  schools;  forces  that  have  hitherto  been  mutually  uncon- 
scious and  wholly  unrelated  as  to  source,  objects  and  methods.  It 
seems  inevitable  that  the  aims  and  objects  of  medical  inspection  are 
only  to  be  accompUshed  by  the  coalescing  of  these  two  forces — each 
contributing  what  the  other  has  lacked. 

On  the  one  hand  is  medical^  science  operating  to  protect  the  com- 
munity through  its  boards  of  health,  while  on  the  other  is  educational 
science  operating  through  the  great  school  systems  of  the  world  and 
expressing  itself  through  its  more  or  less  scientific  departments  of  physical 
training.  Speaking  historically,  medicine  has  labored  to  cure  and  at 
best  prevent  disease  and  deformity,  while  education  has  aimed  at  the 
intellectual  equipment  of  the  individual.  Pathology  is  prominent 
in  the  one  case  and  development  in  the  other. 

That  commimity  protection  has  been  a  chief  aim  from  the  medical 
viewpoint  is  indicated  by  the  facts  that 

(i)  The  detection  of  contagious  disease  has  been  uniformly  the 
obvious  and  initial  activity,  and 

(2)  That  the  records  are  almost,  if  not  entirely,  those  of  disease  or 
deformity. 

That  growth  has  been  the  chief  aim  from  the  educational  standpoint 
is  shown  by  the  facts  that  where  this  work  has  had  any  scientific  basis, 

(1)  Exercise,  cleanliness,  ventilation,  the  importance  of  suitable 
and  adequate  nutrition,  sleep,  etc.,  have  been  primary  objects;  and 

(2)  Records  of  height,  weight,  chest,  girth,  etc.,  have  constituted 
the  primary  elements  recorded. 

The  distinction  between  these  two  forces  is  a  philosophic  one.  It 
would  not  be  true,  for  example,  that  hygienic  knowledge  has  been 
absent  on  the  one  hand  or  medical  knowledge  on  the  other.     The  best 

5 


6  Medical  Inspection  of  Schools 

medical  inspection  has  included  matters  of  personal  hygiene  and  the  best 
physical  training  has  been  directed  by  those  having  medical  equipment. 

Dr.  John  J.  Cronin,  of  New  York  City,  has  made  most  wise,  ex- 
tensive, able  and  best  known  medical  inspection  from  the  standpoint 
of  education,  acting  as  an  agent  of  the  Department  of  Health,  while 
George  W.  Ehler,  of  Cleveland,  has  put  into  operation  a  most  effective 
educational  program  from  the  standpoint  of  medicine. 

It  is  to  the  departments  of  physical  training  in  our  colleges  and 
secondary  schools  that  we  have  to  look  in  the  main  for  our  most  com- 
plete records  of  growth  and  development.  Still  the  classic  and  monu- 
mental work  of  Bowditch  in  measuring  and  weighing  Boston  public 
school  children,  as  well  as  the  work  of  Porter  in  St.  Louis,  and  Boas 
in  Toronto  and  Worcester,  must  not  be  forgotten. 

The  forces  that  are  compelling  these  two  movements  to  coalesce 
consist  in  certain  changes  in  the  constitution  of  society  which  must 
now  be  sketched  briefly.  These  changes  must  be  examined  from 
two  points  of  view : 

(i)  From  that  of  the  welfare  of  the  community  as  such. 

(2)  From  that  of  the  personal  activities  and  functions,  both  physio- 
logical and  social,  of  the  individual. 

Let  us  take  first  the  changes  affecting  the  welfare  of  the  community 
as  such,  involving  an  enlarged  conception  of  the  duties  and  powers 
of  the  Department  of  Health. 

We  have  to  go  back  in  our  American  history  but  a  trifle  over  a 
century  to  discover  that  we  were  a  set  of  rural  communities — the  urban 
population  (cities  of  8000  and  over)  at  that  time  constituting  but  3.3 
per  cent,  of  the  total  population.  Now  we  are  an  urban  nation;  33 
per  cent,  live  in  cities.  This  percentage  includes  wide  territories  and 
vast  sections  that  were  not  at  that  time  a  part  of  our  country.  When 
we  examine  the  progress  of  the  older  and  more  advanced  states,  the 
direction  in  which  we  are  moving  becomes  still  more  evident.  New 
York  has  an  urban  population  of  72  per  cent.;  Massachusetts  91  per 
cent.;  Ohio  48  per  cent.;  Illinois  54  per  cent.,  while  Rhode  Island  has 
95  per  cent.  This  moving  of  the  population  toward  centers  has  rendered 
essential  attention  by  the  commimities  to  the  cleanliness  of  water  supply, 
to  sewerage,  street  cleaning,  problems  of  light  and  air  in  dwellings, 
the  isolation  of  cases  of  contagious  diseases,  the  transportation  of  food 


Nature  and  Aims  of  Medical  Inspection  7 

and  hence  its  preservation  and  guarantee  of  its  purity,  conditions  and 
hours  of  labor  and  a  thousand  other  matters  which  in  a  rural  community 
were  of  importance  to  individual  families  only. 

Of  great  importance  also  is  the  change  that  has  taken  and  is  taking 
place  in  our  racial  stock.  This  is  important  because  standards  of  living, 
of  cleanliness,  of  freedom  from  vermin,  are  being  brought  in  by  recent 
immigrants  which  are  not  only  different  from  those  that  obtained  under 
early  American  conditions,  but  which  are  inimical  to  those  higher 
standards  of  life  that  are  essential  to  the  individuals  in  a  democracy 
that  is  to  endxire.  That  this  is  a  real  and  large  factor  is  shown  by  the 
following  figures  taken  from  the  last  census: 

Per  Cent,  of 
City.  Foreign  Parentage. 

Boston 71.6 

Chicago 77.2 

Cleveland 75.4 

Milwaukee 82.7 

New  York 76.6 

San  Francisco 70.4 

It  is  true  that  the  percentage  of  foreigners  in  these  cities  does  not 
represent  that  in  the  country  at  large.  But  these  are  among  our  largest 
and  most  important  American  centers,  and  the  traditions  that  ultimately 
establish  themselves  in  these  cities  are  altogether  more  important  to 
the  country  at  large  than  would  be  indicated  by  the  mere  percentage 
of  the  total  population  that  these  cities  contain. 

Our  school  systems  have  developed  enormously  during  this  period 
— developed  altogether  faster  than  has  the  population.  Waat  schools 
there  were,  were  widely  separated,  were  carried  on  for  but  a  small 
fraction  of  the  year,  and  were  attended  by  but  an  inconsiderable  fraction 
of  the  children.  That  is,  the  schools  as  such  did  not  present  any  special 
problem  from  the  standpoint  of  community  hygiene.  Now  the  school 
year  lasts  for  ten  months,  and  in  many  cities  vacation  schools  round  out 
the  calendar  year.  So  the  schools  in  their  intimate  commingling  of 
children  from  practically  all  families  for  most,  if  not  all  of  the  year, 
afford  by  far  the  most  extensive  means  for  the  spread  of  contagious 
diseases  that  exist. 

Thus  the  community  through  its  health  boards  has  been  forced 
not  only  to  protect  itself  from  the  spread  of  disease  in  many  ways  quite 


8  Medical  Inspection  of  Schools 

unnecessary  in  the  earlier  period,  but  has  had  to  become  (unconsciously 
even  to  itself)  an  agency  for  the  establishment  of  American  ideals. 
Boards  of  health  have  been  compelled  to  lay  forcible  hands  upon  the 
school,  time  and  again  during  epidemics,  long  before  it  became  recog- 
nized that  the  school  was  permanently  to  be  a  possible  focus  and  distri- 
butor of  disease,  and  hence  needed  permanent  and  thorough  medical 
I        inspection. 

Let  us  turn  now  to  a  consideration  of  those  changes  in  the  constitu- 
tion of  society  which  have  involved  a  readjustment  of  the  physiological 
functions  of  the  individual  in  his  relation  to  the  social  organism. 

In  the  earlier  period,  and  indeed  during  all  of  that  portion  of  man's 
history  which  preceded  the  last  century,  the  bulk  of  the  world's  work 
was  done  by  human  muscle.  It  is  true  that  man  has  made  great  use 
of  the  horse,  camel  and  a  few  other  animals,  that  windmills  and  water 
wheels  and  sails  have  long  performed  incidental  service ;  but  the  general 
fact  remains  that  human  muscles  have  built  the  pyramids,  dug  the 
canals,  erected  the  houses,  tilled  the  fields,  gathered  the  harvests,  made 
the  cloth,  fought  the  battles,  carried  the  water,  hewn  the  wood,  as  well 
as  written  the  books  for  mankind.  It  is  to  be  remembered  in  this  connec- 
tion that  it  has  not  been  a  small  fraction  of  the  people  that  have  been 
chiefly  concerned  in  this  muscular  labor,  but  that  most  of  the  people 
have  been  so  engaged  for  most  of  their  years.  We  must  not  forget 
that  even  during  the  golden  age  of  Greece — the  age  of  Pericles — eight 
out  of  every  ten  of  the  people  were  slaves  who  labored. 

These  conditions  have  changed.  This  is  not  a  matter  that  concerns 
itself  with  the  city  as  contrasted  with  the  country,  and  hence  is  to  be 
cured  by  reverting  to  country  life.  It  has  changed  for  most  of  the  people 
for  most  of  the  years  of  their  lives. 

It  is  not  only  in  the  city  that  one  turns  on  the  gas  instead  of  chopping 
the  kindlings.  The  bulk  of  the  world's  work  is  done,  not  by  human 
or  even  animal  muscle,  and  not  by  vagrant  winds.  Man  has  harnessed 
the  great  powers  of  nature.  He  breaks  his  land  with  the  gang  plow, 
illuminates  his  night  world  with  electricity,  carries  himself  and  his 
goods  with  elevators,  automobiles,  steam  vessels,  railroad  trains,  sub- 
marines and  in  this  century  with  flying  machines.  He  no  longer  sows 
or  reaps  by  hand;  he  makes  his  cloth  and  clothing,  shoes,  hats  and 
even  decorations  by  machines. 


Nature  and  Aims  of  Medical  Inspection  9 

This  change  is  important  most  of  all  to  children,  for  it  involves 
the  two  chief  agencies  that  have  been  responsible  for  their  development 
into  adults  having  strong  vitality  and  clean  morals.  I  refer  to  work  and 
to  play. 

The  horrors  of  child  labor  are  still  with  us,  although  sure  to  disap- 
pear, but  the  normal  work  with  the  parents,  about  and  for  the  home 
has  gone  or  is  going. 

The  all-round  farm  where  a  boy  learned  the  rudiments  of  a  dozen 
trades  has  been  displaced  by  the  specialized  farm.  The  girls  can  no 
longer  work  with  their  mothers  in  carding  the  wool,  making  the  gar- 
ments, managing  the  dairy  or  poultry.  The  small  garden  is  disappear- 
ing save  as  a  luxury,  washing  is  better  and  more  cheaply  done  outside 
the  home,  most  of  the  cooking  and  "putting  up"  is  done  elsewhere. 

It  is  perhaps  unnecessary  to  further  illustrate  the  fact  that  that 
element  through  which  the  children  have  come  into  and  partaken  of 
the  family  labor,  and  so  gradually  have  learned  to  carry  on  the  world's 
work,  has  gone  or  is  going.  But — of  even  greater  importance  from  the 
standpoint  of  this  present  discussion — that  muscular  work  which 
strengthened  the  muscles,  enlarged  the  chest,  and  aided  in  giving  the 
power  to  live  is  largely  gone. 

The  other  great  source  of  muscular  exercise  and  physical  develop- 
ment which  has  been  the  heritage  of  all  of  the  children  of  all  of  the 
world  is  play.     This  is  being  attacked  from  three  sources,  namely 

Time  for  play 
Space  for  play 
Traditions  for  play. 

School  life  has  increased  to  cover  six  hours  a  day  for  ten  months 
a  year.  The  school  has  pressed  its  importance  till  "home  work" 
takes  from  one  to  four  hours  of  the  rest  of  the  day.  Our  children  are 
busy  most  of  the  time.  There  is  little  time  left  for  quiet  play  with  dolls, 
wandering  through  the  woods,  or  corresponding  activities  in  which  un- 
conscious growth  occurs. 

We  are  already  an  urban  country  and  are  rapidly  becoming  more  so. 
Not  one  city  has  been  planned  with  the  real  object  of  human  life  in  mind, 
that  is,  the  rearing  of  healthy,  happy  children.  Every  other  crop  has 
been  provided  for  but  this  one,  and  yet  this  one  transcends  them  all 


10  Medical  Inspection  of  Schools 

even  in  financial  value.  Our  cities  are  being  built  up  without  play- 
grounds. Millions  and  millions  have  been  spent  on  the  Island  of  Man- 
hattan to  remedy  this  lack  of  forethought,  but  allowing  a  scant  space 
of  three  yards  square  for  each  child,  only  one  child  in  ten  can  be  given 
play  room  south  of  Fourteenth  Street  in  this  city.  This  is  one  of  the 
reasons  for  the  prevalence  of  such  games  as  craps.  It  takes  but  little 
space,  is  quiet,  can  be  played  with  a  varying  number  of  players,  is 
interesting,  etc.  In  fact,  it  is  an  ideal  game  for  city  children,  with  a 
single  reservation.  It  is  bad  for  their  morals  and  useless  as  a  developer 
of  muscle  or  physical  stamina. 

The  great  games  of  the  world  that  have  been  handed  down  from  child 
to  child  for  hundreds  or  even  thousands  of  generations,  preserved 
in  the  amber  of  child  tradition,  do  not  in  the  main  suit  modern  city 
conditions. 

Children  do  not  bring  their  play  traditions  with  them.  It  would 
seem  as  if  a  dozen  families  from  a  dozen  lands  would  form  a  little  com- 
munity with  a  wealth  of  childlore  and  games,  but  such  is  not  the  case.^ 
They  only  play  what  they  have  in  common,  and  these  are  the  most 
elementary  games  suited  only  to  the  younger  children.  This  condition 
with  reference  to  the  absence  of  adequate  traditions  carrying  suitable 
plays  applies  to  the  country  and  village  districts  as  much  as  it  does 
to  the  cities.  The  play  of  our  country  children  is  about  as  inadequate 
as  is  that  of  our  city  children.  This  is  not  a  matter  of  poverty.  The 
exquisitely  dressed  children  led  by  the  hand  along  Riverside  Drive, 
New  York,  in  order  that  they  may  "get  the  air"  are  a  more  pathetic 
sight  than  are  the  equally  healthy  though  dirty  children  one  sees  play- 
ing on  the  East  Side.  That  these  conditions  are  actually  resulting  in 
decreased  p)ower  to  live  is  shown  by  several  extensive  studies  made  in 
Great  Britain  during  the  past  decade. 

We  have  massed  here  several  groups  of  facts  bearing  more  or  less 
closely  on  the  alterations  of  children's  lives  that  have  occurred  or  are 
occurring  to  show  the  situation  that  is  back  of  the  movement  for  physical 
training,  playgrounds,  etc.,  in  departments  of  education. 
/  The  state  provides  for  the  education  of  all  citizens  as  a  measure 
of  self-protection.  The  facts  given  show  that  the  state  must  also  take 
cognizance  of  their  physical  welfare  for  the  same  reason.  Health  and 
education  belong  hand  in  hand.     This  means  that  the  existing  educa- 


Nature  and  Aims  of  Medical  Inspection  1 1 

tional  agencies  must  ally  with  themselves  expert  medical  officers  who  ^ 
shall  see  that  the  health  of  children  is  conserved  through  the  schools. 
This  cannot  be  an  incidental  activity  of  some  department,  but  must 
outrank  all  others  in  power,  as  it  does  in  importance.  ^ 

Medical  inspection,  then,  aims  at  both  the  protection  of  the  community  -  - 
and  furnishing  the  physical  conditions  under  which  wholesome  life  can 
develop.     It  involves  in  this  comprehensive  aim  the  functions  of  both 
the  departments  of  health  and  of  education. 


CHAPTER  II 

The  Argument  for  Medical  Inspection 

Since  the  days  of  Juvenal,  men  have  been  quoting  his  much  abused 
half-line,  "/A  sound  mind  in  a  sound  body\ ;  and  while  making  diligent 
provisions  for  schools  in  which  "sound  minds"  were  to  be  shaped,  have 
felt  that  these  schools  needed  little  scrutiny  as  to  their  fitness  for  con- 
serving and  developing  "  sound  bodies". 

The  famous  Spanish  voyager  who  lost  his  life  in  his  futile  search 
for  the  phantom  fountain  of  youth  was  far  from  being  the  first  or  the 
last  of  the  long  line  of  seekers  for  a  "cure-all"  which  should  eradicate 
the  ailments  of  old  age  and  restore  that  buoyant  health  of  youth  which 
modern  science  is  just  beginning  to  teach  us  must  be  diligently  con- 
served from  childhood,  if  it  is  to  be  enjoyed  in  after-life. 

To  say  that  we  have  during  all  this  time  lost  sight  of  the  true  source 
of  a  healthy  old  age  would  be  an  extreme  statement,  but  it  is  certainly 
true  that  educators  in  general  have  given  but  scanty  and  fleeting  atten- 
tion to  the  problem  of  the  physical  well-being  of  their  charges. 

All  too  often  the  same  complacent  and  care-free  attitude  of  mind 
has  been  shared  by  the  parent.  All  children  had  to  have  the  "  common 
children's  diseases" — and  the  sooner,  the  better.  If  Johnny  breathes 
through  his  mouth — "  He  always  did  that.  He  will  outgrow  it."  The 
child's  cough  is  only  "a  slight  cold."  "He  always  turns  his  head  to 
one  side  when  he  writes  or  reads.  It's  a  habit  he  has  got  into.  He 
has  always  been  pale.     It  is  nothing  unusual." 

In  cases  of  serious  epidemics  it  has  always  been  recognized  that 
parents  have  the  right  to  insist  that  the  schools  shall  be  safe  places 
for  them  to  send  their  children.  This  right  has  been  recognized  by  the 
closing  of  the  public  schools  during  an  epidemic;  but  despite  the  fact 
that  it  has  long  been  recognized  that  the  public  school  serves  as  a  center 
of  exchange  for  contagious  diseases  which  pass  from  pupil  to  pupil, 


The  Argument  for  Medical  Inspection  13 

the  occasional  closing  down  and  the  rare  fumigation  have  constituted 
the  sum  total  of  preventive  measures,  with  the  single  exception  of  the 
commonly  insisted  on  requirement  of  vaccination. 

Again,  except  in  extreme  cases,  the  school  has  taken  little  note  of 
such  defects  of  mind  and  body  as  might  vitally  affect  the  chances  of 
success  and  happiness  of  the  child,  unless  such  defects  were  of  the  more 
directly  alarming  nature  of  contagious  diseases. 

The  "lockstep"  has  been  the  rule  in  physical  matters,  as  in  the 
realm  of  the  course  of  study.  All  the  children  have  been  received  on  an 
equality  and  have  been  treated  equally,  no  matter  what  their  mental 
endowments  or  physical  condition.  The  quick  and  the  slow,  the  sound 
and  the  sick,  have  been  grouped  together;  and  he  who  could  not  keep 
his  place  in  his  studies  has  been  as  unquestioningly  left  behind  as  has 
he  who  through  illness  could  not  retain  his  place  in  the  school. 

That  such  a  course  was  poor  business  policy,  based  on  the  false 
assumption  of  a  universal  mental  and  physical  equality  which  does  not 
exist,  has  been  pointed  out  times  without  number.  As  in  all  movements, 
the  leaders  have  been  far  in  advance  of  the  rank  and  file;  and  in  our 
own,  as  in  other  countries,  the  great  majority  of  people  have  been  too 
much  engaged  in  their  special  interests  to  give  heed  to  the  great  problems 
involved  in  the  work  of  improving  the  educational  and  physical  well- 
being  of  the  young  of  the  race. 

With  the  great  changes  which  have  been  coming  over  American 
life,  former  conditions  have  disappeared  and  this  undisturbed  indifiference 
has  become  impossible.  We  have  changed  from  an  agricultural  people 
to  a  race  of  dwellers  in  towns  and  cities.  The  school  year  has  changed 
from  a  three  months'  winter  term  to  one  of  five  hours  per  day  for  ten 
months  during  the  year.  The  number  of  years  of  school  life  has  greatly 
increased.  We  have  passed  compulsory  education  laws.  Going  to 
school  has  become  not  only  the  normal,  but  the  required  occupation 
of  all  children  for  a  considerable  number  of  years. 

The  results  of  these  changed  conditions  on  the  health  of  children 
have  become  so  marked  as  to  insistently  demand  attention.  The 
parents,  school  authorities,  and  health  authorities  have  been  unable 
to  avoid  recognizing  the  fact  that  in  the  nature  of  the  case  the  school 
has  become  the  most  certain  center  of  infection  in  the  community. 

From  these  conditions  grew  up  medical  inspection,  for  the  purpose 


14  Medical  Inspection  of  Schools 

of  detecting  cases  of  contagious  diseases  and  of  segregating  such  cases 
for  the  protection  of  other  children.  Wherever  established,  the  good 
results  of  medical  inspection  have  been  evident.  Epidemics  have 
been  checked  or  avoided.  Improvements  have  been  noted  in  the 
cleanliness  and  neatness  of  the  children.  Teachers  and  parents  have 
come  to  know  that  under  the  new  system  it  is  safe  for  children  to  con- 
tinue in  school  in  times  of  threatened  or  actual  epidemic. 

But  medical  inspection  does  not  stop  here,  nor  has  it  limited  its 
activities  to  the  field  outlined.  Other  problems  have  been  insistently 
forcing  themselves  on  the  attention  of  school  men;  and  they,  knowing 
something  of  the  wonderful  advances  made  in  the  field  of  medicine, 
have  turned  for  aid  to  the  physicians. 

With  the  changes  in  the  length  of  the  school  term  and  the  increase 
in  the  number  of  years  of  schooling  demanded  of  the  child,  has  come 
a  great  advance  in  the  standards  of  the  work  required.  When  the  stand- 
ards were  low,  the  work  was  not  beyond  the  capacity  of  even  the  weaker 
children;  but  with  close  grading,  fuller  courses,  higher  standards, 
and  constantly  more  insistent  demands  for  intellectual  attainment, 
this  has  changed.  Pupils  have  been  unable  to  keep  up  with  their  classes. 
The  terms  "backward,"  "retarded,"  "exceptional"  as  applied  to  school 
children  have  been  added  to  the  vocabularies  of  the  school  men.  In- 
quiries have  been  instituted  into  the  causes  underlying  the  phenomena 
of  backward  and  retarded  children,  of  those  who  are  unable  to  keep  up 
with  their  classes,  or  those  who  seem  to  be  different  from  their  com- 
panions in  their  ability  to  do  the  work  demanded. 

As  a  result  of  these  inquiries,  physical  examinations  have  been 
conducted  by  the  doctors  connected  with  the  schools.  Surprising  num- 
bers of  children  have  been  found  who  through  defective  eyesight  have 
been  seriously  handicapped  in  their  school  work.  Many  are  found 
to  have  defective  hearing.  Other  conditions  are  found  which  have 
a  great  and  formerly  unrecognized  influence  on  the  welfare,  happiness, 
and  mental  vigor  of  the  child.  Attention  has  been  directed  to  the 
real  significance  of  adenoids  and  enlarged  tonsils,  of  swollen  glands 
and  carious  teeth. 

Persistently,  earnestly  and  quietly  this  work  has  been  pushed  to  a 
successful  experimental  accomplishment,  and  as  a  result  we  have  to-day 
medical  inspection  in  its  various  forms — not  only  for  the  detection  of 


The  Argument  for  Medical  Inspection  15 

contagious  disease,  but  also  for  discovering  those  physical  defects 
which  interfere  with  the  child's  ability  to  do  his  school  work,  or  which, 
if  neglected,  will  seriously  affect  his  physical  efficiency  in  after-life. 
The  movement  as  a  whole  constitutes  both  a  sign  and  a  result  of  the 
gradual  awakening  which  has  developed  into  a  wave  of  interest  in 
matters  that  pertain  to  the  health  of  school  children  that  is  now  sweep- 
ing over  the  civilized  world. 

Communities  are  seeing  the  whole  matter  in  a  new  light.  Gradually 
they  are  beginning  to  ask — not  whether  they  can  afford  to  take  steps 
to  safeguard  in  schools  the  welfare  of  their  children,  but  whether  they 
can  afford  not  to  take  such  steps.  The  realization  is  dawning  that  it 
is  unbusinesslike  to  count  carefully  the  cost  of  the  school  doctor,  but  to 
disregard  the  cost  of  death  and  disease,  of  wrecked  hopes  and  dependent 
families. 

Teachers  and  parents  are  commencing  to  realize  that  from  their 
viewpoint  and  from  that  of  the  school  physician  the  problem  of  the 
pupil  with  defective  eyesight  may  be  quite  as  important  to  the  com- 
munity as  that  of  the  child  who  has  some  contagious  disease.  This 
child,  placed  in  a  school  where  physical  defects  are  unrecognized  and 
disregarded,  is  unable  to  see  distinctly,  and  headaches,  eye-strain,  and 
failure  follow  all  his  efforts  at  study.  He  cannot  see  the  blackboards 
and  charts,  printed  books  are  indistinct  or  are  seen  only  with  much 
effort — everything  is  blurred.  Neither  he  nor  his  teacher  knows  what 
is  the  matter,  but  he  soon  finds  it  impossible  to  keep  pace  with  his 
companions,  and,  becoming  discouraged,  he  falls  behind  in  the  unequal 
race. 

In  no  better  plight  is  the  child  suffering  from  enlarged  tonsils  and 
adenoids,  which  prevent  proper  nasal  breathing  and  compel  him  to 
keep  his  mouth  open  in  order  to  breathe.  Perhaps  one  of  his  troubles 
is  deafness.  He  is  soon  considered  stupid.  This  impression  is  strength- 
ened by  his  poor  progress  in  school.  Through  no  fault  of  his  own 
he  is  doomed  to  failure.  He  neglects  his  studies,  hates  his  school, 
leaves  long  before  he  has  completed  the  course,  and  is  well  started  on 
the  road  to  an  inefficient  and  despondent  life. 

/Public  schools  are  a  public  trustV  When  the  parent  delivers  his 
child  to  their  care,  he  has  a  right  to  insist  that  the  child  under  the  super- 
vision of  the  school  authorities  shall  be  safe  from  harm  and  will  at 


i6  Medical  Inspection  of  Schools 

least  be  handed  back  to  him  in  as  good  condition  as  he  was  at  first. 
Not  only  has  the  parent  the  right  to  claim  such  protection,  but  even 
if  he  does  not  insist  upon  it,  the  child  himself  has  a  right  to  claim  it. 
;The  child  has  a  claim  upon  the  state  and  the  state  a  claim  upon  the 
'  child  which  demand  recognition.  In  the  words  of  Dr.  William  H. 
Allen:  "When  the  state  for  its  own  protection  compels  a  child  to  go 
to  school,  it  pledges  itself  not  to  injure  itself  by  injuring  the  child." 
We  are  beginning  to  find  out  that  many  of  our  backward  pupils  are 
backward  purely  and  simply  because,  through  physical  defects,  they 
are  unable  to  handle  the  work  of  the  school  program.  Wliat  these 
defects  are  and  the  causes  that  lie  behind  them  are  things  that  we  must 
know.  If  we  do  not  know  them,  we  must  find  them  out  and  guard 
against  them.  Education  without  health  is  useless.  It  would  be  better 
to  sacrifice  the  education  if,  in  order  to  attain  it,  the  child  must  lay 
down  his  good  health  as  a  price.  Education  must  comprehend  the  whole 
man  and  the  whole  man  is  built  fundamentally  on  what  he  is  physi- 
cally. Children  are  not  dullards  or  defectives  by  the  will  of  an  inscru- 
table Providence,  but  rather  by  the  law  of  cause  and  effect. 

The  objection  that  the  state  has  no  right  to  permit  or  require  medical 
/  inspection  of  the  children  in  the  schools  will  not  bear  close  scrutiny  nor 
'  logical  analysis.  The  authority  which  has  the  right  to  compel  attendance 
at  school  has  the  added  duty  of  insisting  that  no  harm  shall  come  to  those 
who  go  there.  The  Massachusetts  law,  with  its  mandatory  "shall,"  is 
certainly  preferable  to  the  New  Jersey  law,  with  its  permissive  "may." 
The  exercise  of  the  power  to  enforce  school  attendance  would  be  dan- 
gerous if  it  were  not  accompanied  with  the  appreciation  of  the  duty 
of  seeing  that  the  assembling  of  pupils  brings  to  the  individual  no  physical 
detriment.  When  the  subject  is  considered  both  from  the  standpoint 
of  the  individual  and  from  that  of  the  state,  the  wonder  is  not  that 
medical  inspection  is  now  being  agitated,  but  rather  that  it  was  not 
long  ago  put  into  practice. 

Nor  is  the  state,  in  assuming  the  medical  oversight  of  the  pupils 
in  the  public  schools,  trespassing  upon  the  domain  of  private  rights  and 
initiative.  American  systems  do  not,  like  the  feeding  of  school  children 
(already  resorted  to  in  France  and  in  parts  of  England),  lessen  the  respon- 
sibility of  the  parent  or  tend  to  weaken  or  supersede  the  home.  Under 
medical  inspection  absolutely  nothing  is  done  for  the  parent  but  to  tell 


y 


The  Argument  for  Medical  Inspection  17 

him  of  the  needs  of  his  child,  of  which  he  would  otherwise  have  been 
in  ignorance.  It  leaves  it  to  the  parent  to  meet  those  needs.  It  leaves 
him  with  a  larger  responsibility  than  before.  Whatever  view  be  taken 
of  the  right  of  the  state  to  enforce  measures  for  the  correction  of  defects 
discovered,  the  arguments  for  and  against  do  not  enter  into  the  present 
discussion.  It  seems  diflScult  to  find  a  logical  basis  for  the  argument 
that  the  state  has  not  the  right  to  inform  the  parents  of  defects  present 
in  the  child,  and  to  advise  as  to  remedial  measures  which  must  be  taken 
to  remove  them. 

The  justification  of  the  state  in  assuming  the  fimction  of  education 
and  in  making  that  education  compulsory  is  to  insure  its  own  preserva- 
tion and  efl&ciency.  Whether  or  not  it  is  to  be  successful  will  depend 
on  its  individual  members.  But  the  well-being  of  a  state  is  as  much 
dependent  upon  the  strength,  health,  and  productive  capacity  of  its 
members  as  it  is  upon  their  knowledge  and  intelligence.  In  order  that 
it  may  insure  the  efi&ciency  of  its  citizens,  the  state  through  its  compulsory 
education  enactments  requires  its  youth  to  pursue  certain  studies  which 
experience  has  proved  necessary  to  secure  that  efl5ciency.  Individual 
efficiency,  however,  rests  not  alone  on  education  or  intelligence,  but  is 
equally  dependent  on  physical  health  and  vigor.  Hence,  if  the  state 
may  make  mandatory  training  in  intelligence,  it  may  also  command 
training  to  secure  physical  soundness  and  capacity. 

Much  time  may  elapse  before  there  will  be  brought  to  bear  in  all 
schools  the  measures,  now  so  successfully  pursued  in  some,  for  conserv- 
ing and  developing  the  physical  soundness  of  rising  generations.  But, 
nevertheless,  the  movement  is  so  intimately  related  to  the  future  welfare 
of  our  country  and  is  being  pushed  with  so  great  energy  and  earnestness 
by  its  advocates  that  it  is  destined  to  be  successful  and  permanent. 

Not  alone  oiir  imwillingness  to  be  outdone  in  this  public  service 
by  foreign  nations,  not  alone  our  sense  of  practical  foresight,  but  our 
inherent  feeling  of  obligation  toward  our  children  and  our  recognition 
of  this  service  as  one  of  necessity  for  the  national  well-being,  are  forcing 
upon  us  the  incorporation  of  this  phase  of  public  activity  as  an  integral 
part  of  ovu:  public  education. 


CHAPTER  III 

Historical 

A  Sketch  of  the  Rise,  Development  and  Present 
Status  of  Medical  Inspection  at  Home  .and  Abroad 

Medical  inspection  of  schools  is  a  movement  of  recent  growth, 
although  it  is  by  no  means  in  its  infancy  and  has  long  since  passed 
its  experimental  stage. 

In  France  the  law  of  June  28,  1833,  charged  the  school  committees 
of  the  cities  and  towns  with  the  care  of  keeping  the  school  houses  cfean, 
while  a  royal  ordinance  of  December  22,  1837,  made  it  the  special  duty 
of  the  female  supervisors  of  maternal  schools  (kindergartens)  to 
watch  over  the  health  of  the  little  children.  In  Paris  separate  govern- 
mental decrees  were  issued.  The  decrees  of  1842  and  1843  ordered 
that  every  public  boys'  and  girls'  school  should  be  visited  by  a  physician 
who  was  to  inspect  the  localities  and  the  general  health  of  the  school 
children.  This  arrangement,  while  praiseworthy  in  purpose,  had  the 
great  drawback  of  not  being  supported  by  the  annual  budgets.  Hence 
an  appeal  to  the  generosity  of  the  medical  fraternity  was  necessary. 
Many  physicians  offered  their  services  and  gave  them  gratuitously  for 
years. 

In  1879  the  General  Council  of  the  Department  of  the  Seine  voted 
to  reorganize  the  medical  service  in  the  schools  and  passed  an  appro- 
priation for  the  payment  of  salaries  to  the  physicians.  The  department 
was  divided  into  114  districts,  of  which  88  were  within  the  city  of  Paris. 
A  physician  was  placed  in  charge  of  the  work  in  a  district,  and  each 
district  contained  from  20  to  25  school  rooms.  In  January,  1884,  the 
service  was  again  reorganized.  Needed  regulations  were  drawn  up 
and  the  districts  were  changed  so  as  to  give  each  inspector  from  15  to 
20  school  rooms.  It  is  from  this  year — 1884 — that  the  present  institu- 
tion of  medical  supervision  of  schools  in  Paris  dates. 


Historical  19 

The  organization  there  has  served  as  a  model  for  similar  arrange- 
ments in  other  French  cities.  Through  the  school  law  of  1886,  as 
well  as  through  ministerial  decrees  and  orders  dated  1887,  medical 
and  sanitary  inspection  has  been  made  obligatory  in  all  French  schools, 
public  and  private.  To  the  city  of  Havre  belong  the  honor  and  credit 
of  having  the  first  free  public  dispensary  for  children.  It  was  founded 
in  1875. 

Probably  the  first  system  of  medical  inspection  in  the  full  modern 
sense  of  the  term  was  that  inaugurated  in  Brussels  in  Belgium  in  1874, 
when  school  physicians  were  appointed  who  were  required  to  visit 
schools  three  times  per  month.  So  successful  did  the  system  prove 
that  it  was  soon  copied  in  Antwerp,  Louvain,  Liege,  and  other  cities, 
and  served  as  a  model  for  systems  in  Switzerland.  Moreover,  in  view 
of  the  favorable  results  in  Brussels,  dentists  and  oculists  were  likewise 
appointed  to  visit  the  pupils  regularly. 

In  Germany,  Leipsic  and  Dresden  were  the  first  cities  to  have 
medical  inspection.  A  beginning  was  made  in  Dresden  in  1867,  when 
three  physicians,  formerly  teachers  of  physical  training,  were  intrusted 
with  the  examination  of  children  in  cases  of  epidemic  eye  disease;  but 
these  were  not  fully  equipped  school  physicians.  Not  until  1889  was 
a  system  of  true  medical  inspection  established.  The  movement  spread 
rapidly  and  was  taken  up  by  city  after  city.  In  Wiesbaden  a  system 
was  developed  providing  for  a  careful  and  thorough  physical  examination 
of  each  child  at  the  time  of  entering  school,  and  for  a  re-examination 
in  the  third,  fifth,  and  eighth  years  of  the  public  school  course.  The 
system  also  provides  for  careful  service  for  the  detection  of  contagious 
diseases  and  for  the  inspection  of  school  buildings  and  surroundings. 
In  1898  the  Wiesbaden  method  of  school  inspection  was  generally 
adopted  throughout  Germany. 

Wiesbaden  Plan  of  School  Inspection 

With  the  introduction  of  the  Wiesbaden  method  of  school  inspection 
began  a  new  epoch  in  the  development  of  the  school  systems  of  Ger- 
many. The  chief  characteristic  of  this  method  lies  in  a  strong  emphasis 
upon  the  hygiene  of  the  school  child,  without  in  any  way  neglecting  the 
hygiene  of  the  school  building.     Medical    inspection   in  the  schools 


20  Medical  Inspection  of  Schools 

of  Germany,  which  previous  to  the  introduction  of  this  plan  had  lagged, 
has  since  its  adoption  gained  rapidly. 

Wiesbaden  was  the  first  German  city  to  make  a  test  examination 
of  all  pupils,  whereby  an  unusually  high  percentage  of  defects  was 
revealed,  of  which  the  pupil,  the  teacher,  and  the  parents  were  wholly 
ignorant.  It  became  apparent  to  the  Wiesbaden  authorities  that  a 
medical  examination  of  at  least  all  children  entering  school  was  of  the 
utmost  importance.  The  result  of  the  trial  examination  led  to  the 
establishment  of  a  system  of  regular  examinations. 

The  provisions  of  the  Wiesbaden  plan  are:  systematic  examination 
of  heart,  lungs,  throat,  spine,  skin,  and  the  higher  sense  organs  (and 
in  the  case  of  boys  also  examination  for  hernia).  The  findings  are 
entered  on  a  report  blank,  which  accompanies  the  child  from  grade  to 
grade  in  his  school  life.  Twice  a  year  the  teacher  records  the  height 
and  weight  of  individual  pupils.  Wherever  it  is  deemed  necessary, 
the  school  physician  takes  chest  measurements.  The  records  of  children 
who  seem  to  require  the  regular  care  of  a  physician  are  marked  accord- 
ingly, and  these  children  report  at  regular  intervals  to  the  school  physi- 
cian. A  careful  re-examination  of  all  pupils  must  be  made  in  their 
third,  fifth,  and  eighth  school  years.  It  is  the  duty  of  the  school  physi- 
cian to  give  advice  to  the  teacher  with  reference  to  the  child.  In  cases 
of  defects  requiring  medical  attention,  the  parents  of  the  child  are 
notified.  It  is  not  the  function  of  the  school  physician  to  give  treat- 
ment. 

In  Himgary  the  law  of  1887  provided  for  school  physicians  to  visit 
the  institutions  of  learning.  Their  duties  are:  the  hygienic  supervision 
of  school  rooms,  the  detailed  examination  of  all  children  entering  school, 
and  the  giving  of  lectures  in  the  schools  with  reference  to  hygiene. 

In  Austria  medical  inspection  of  schools  is  an  affair  of  the  state. 
In  the  different  crown  lands  it  is  under  the  Provincial  Councilor  of 
Education,  in  the  school  districts  under  the  district  school  boards,  and 
in  the  different  communities  under  the  local  school  boards. 

In  Norway  the  instructions  have  been  enforced  since  1899,  to  the 
effect  that  with  the  consent  of  the  local  administration,  a  physician 
may  inspect  the  health  of  school  children;  but  by  the  decree  of  Septem- 
ber 24,  189 1,  this  regulation  was  extended  so  that  the  health  of  pupils 


Historical  21 

must  be  examined  three  times  per  year, — in  May,  August,  and  Decem- 
ber,— and  the  report  drawn  up  in  prescribed  form  by  the  board  of 
teachers  and  physicians,  who  are  to  give  special  attention  to  the  causes 
of  absences  from  school,  headache,  and  fatigue. 

Sweden  is  probably  the  country  where  the  term  "school  physician" 
in  the  modern  sense  was  first  employed,  though  at  first  the  duties  of 
school  physicians  did  not  comprehend  the  work  done  by  them  at  the 
present  day.  In  1863  they  were  only  obliged  to  examine  with  reference 
to  exemption  from  gymnastic  exercises.  In  1874  committees  on  health 
were  given  charge  of  the  schools,  especially  with  reference  to  ventilation, 
and  since  1878  school  physicians  have  been  required  to  examine  the 
health  of  children  at  the  beginning  of  the  term  and  to  report  the  results. 

In  Roumania,  by  the  decree  of  April  5,  1899,  special  physicians  are 
required,  either  themselves  or  in  the  persons  of  district  physicians,  to 
examine  all  school  children  at  least  once  a  year;  to  inspect  buildings 
with  reference  to  construction  and  equipment  (heating,  light,  cleanliness, 
drinking-water,  privies,  etc.);  to  supervise  all  that  touches  in  any  way 
on  the  subject  of  health,  and  to  submit  propositions  to  the  proper  authori- 
ties for  supplying  existing  wants  and  remedying  evils. 

Moscow  has  had  school  physicians  in  her  schools  since  1888.  It 
is  the  duty  of  these  physicians  to  examine  all  the  pupils  once  a  year 
and  to  make  reports  on  the  "sanitary  lists"  of  the  children.  Since 
1895  six  physicians  have  been  in  charge  of  health  matters  in  the  72 
elementary  schools,  and  since  1888  two  female  physicians  have  been 
employed  at  the  girls'  high  school.  Besides  their  other  functions, 
these  physicians  are  required  to  vaccinate  and  revaccinate,  to  treat  poor 
sick  pupils  free  of  charge,  and  to  manage  affairs  in  cases  of  epidemics. 

In  Switzerland  medical  inspection  has  become  a  national  movement, 
although  governed  by  different  regulations  in  the  several  cantons. 

In  England  the  medical  inspection  act,  which  went  into  effect  January 
I,  1908,  is  national  in  its  scope  and  applies  to  all  the  public  elemen- 
tary schools.  It  is  thorough  in  its  provisions  for  a  complete  system 
of  medical  supervision.  Its  high  purposes  are  expressed  in  a  memoran- 
dum of  the  Board  of  Education,  in  the  following  words: 

"It  is  founded  on  a  recognition  of  the  close  connection 
which  exists  between  the  physical  and  mental  condition 


22  Medical  Inspection  of  Schools 

of  the  children,  and  the  whole  process  of  education.  It 
recognizes  the  importance  of  a  satisfactory  environment, 
physical  and  educational,  and  by  bringing  into  greater 
prominence  the  effect  of  environment  upon  the  personality 
of  the  individual  child,  seeks  to  secure  ultimately  for  every 
child,  normal  or  defective,  conditions  of  life,  compatible 
with  that  full  and  effective  development  of  its  organic 
functions,  its  special  senses,  and  its  mental  powers,  which 
constitute  a  true  education." 

For  the  purpose  of  putting  into  operation  the  provisions  of  this  act, 
the  county  educational  committees  throughout  England  have  been 
taking  active  steps  in  creating  the  necessary  machinery  and  perfecting 
existing  organizations  of  medical  officers.  Already  there  is  a  national 
Society  of  Medical  Officers  for  Schools. 

In  France  such  a  society  has  long  existed  and  has  now  reached  a 
degree  of  strength  and  importance  which  has  prompted  it  to  begin  the 
publication  of  a  monthly  entitled,  "La  Medecine  Scolaire,"  the  bulletin 
of  the  Society  of  Medical  Inspectors  of  Schools.  Volume  I,  No.  i, 
appeared  on  February  lo,  1908.  The  deep  purpose  which  actuates 
the  leaders  of  the  movement  in  France  is  expressed  in  the  introductory 
editorial  of  the  first  number  of  the  magazine.  The  editorial  is  entitled, 
"  Our  Program,"  and  begins  as  follows: 

"The  purpose  of  protecting  children  and  of  assuring 
them  their  best  physical  and  intellectual  development  has 
for  several  years  been  assuming  an  ever-increasing  impor- 
tance. In  this  movement  in  favor  of  all  that  pertains  to 
conserving  the  health  of  children — in  the  work  which 
Prof.  Pinard  has  called  '  puericulture ' — France  has  taken 
an  important  part.  Indeed,  for  France  this  has  become 
a  most  important  duty,  because  the  study  of  these  ques- 
tions has  a  higher  importance  in  this  country  than  in  more 
favored  countries,  where  the  question  of  the  increase  of 
population  does  not  constitute  one  of  the  vital  problems 
of  the  day." 

After  going  on  to  describe  the  purposes  of  the  Association  of  School 


o 

G 

Historical  23 

Medical  Inspectors,  and  after  studying  some  of  the  important  work 
done  by  the  society  in  the  past,  the  pubHcation  of  the  new  journal  is 
introduced  with  the  words,  "To-day  the  Society  of  Medical  Inspectors 
of  Schools  wishes  to  complete  its  work  by  the  publication  of  the  journal, 
^  La  Medecine  Scolaire.'  " 

But  Europe  and  America  are  not  the  only  parts  of  the  world  that 
have  been  receiving  the  benefits  of  medical  inspection.  Since  1882 
in  Cairo,  Egypt,  a  school  physician  has  been  employed  at  a  salary  of 
12,000  francs,  besides  two  assistants,  each  with  a  salary  of  3600  francs, 
having  the  supervision  of  5000  pupils. 

In  Chile  in  1888  the  supervision  of  schools  was  intrusted  to  a  Provin- 
cial Council,  including  a  physician  as  a  member,  and  the  supreme 
direction  of  sanitary  affairs  was  given  in  charge  of  a  superior  board  of 
public  health,  composed  of  seven  members.  School  physicians  in 
Chile  are  required  to  visit  each  school  at  least  once  a  month,  inspect 
the  sanitary  condition  of  buildings  and  surroundings,  inform  them- 
selves of  the  condition  of  health  among  the  children,  make  note  of  their 
observations,  and  hand  in  a  monthly  report. 

In  the  Argentine  Republic  great  interest  in  medical  inspection 
has  been  manifested,  and  the  system  is  credited  with  being  one  of  the 
most  complete  and  efficient  in  existence.  It  provides  for  the  vaccina- 
tion of  school  children,  examination  of  the  sanitary  condition  of  school 
buildings,  the  visiting  of  sick  children  in  their  homes,  the  prevention 
of  contagious  diseases,  the  delivering  of  regular  scientific  lectures,  and 
the  giving  of  free  medical  advice  to  the  teachers  as  well  as  to  the  pupils. 

In  Japan  in  1898  the  Minister  of  Education  directed  the  nomination 
of  salaried  school  physicians  in  all  public  schools.  Frederick  J.  Haskin, 
writing  of  the  work  there  in  1898,  says: 

"The  Japanese  system  of  medical  inspection  extends 
all  over  the  empire  and  reaches  the  most  remote  rural 
community.  Thus  the  Japanese  department  of  education 
is  able  to  tell  how  many  children  are  in  school  in  the 
empire,  how  many  are  robust,  medium,  or  weak,  how 
many  have  defective  eyesight,  and  what  diseases  are  most 
prevalent  at  different  ages  of  school  life.  The  department 
can  also  tell  how  many  children  in  school  at  the  age  of 


o 


% 


24  Medical  Inspection  of  Schools 

fifteen  years  were  150  cm.  tall,  how  many  weighed  40  kg., 
and  how  many  had  a  chest  measurement  of  75  cm.  They 
can  also  tell  the  averages  of  all  these  statistics  and  the 
percentages  of  robust  boys  or  fat  girls." 

In  the  United  States  the  first  regular  system  of  medical  inspection 
seems  to  have  been  in  Boston  in  1894.  Before  this,  however,  in  New 
York  in  1892,  Dr.  Cyrus  Edson,  then  Sanitary  Superintendent,  appointed 
Dr.  Moreau  Morse,  Medical  Inspector  of  Schools.  Dr.  Morse  was 
probably  the  first  public  medical  school  officer  to  be  appointed  in  this 
country. 

In  Boston  the  need  of  medical  inspection  of  schools,  for  the  purpose 
of  detecting  contagious  and  other  diseases  among  the  school  children, 
was  brought  to  the  attention  of  the  mayor  and  city  council  in  1892; 
and  for  this  purpose  an  appropriation  was  then  secured.  A  delay  of 
several  months  was  occasioned  in  securing  the  approval  of  the  school 
committee,  so  that  the  plan  did  not  finally  go  into  operation  until  Novem- 
ber, 1894,  when  the  Board  of  Health  selected  50  physicians  for  this 
purpose,  divided  the  city  into  50  school  districts,  and  began  school 
inspection. 

In  New  York  the  Board  of  Health,  at  a  meeting  held  March  16, 
1897,  appointed  134  medical  inspectors  for  public  schools.  Dr.  A. 
Blauvelt,  formerly  assistant  chief  of  the  Bureau  of  Contagious  Diseases, 
was  appointed  chief  inspector  at  an  annual  salary  of  $2500. 

Chicago  in  1895  was  divided  into  nine  districts  for  the  purpose  of 
the  inspection  of  schools.  One  medical  inspector  was  assigned  to  each 
district,  giving  each  inspector  an  oversight  of  more  than  20  square 
miles. 

In  Philadelphia  the  Bureau  of  Health  passed  the  following  resolu- 
tion on  June  7,  1898: 

"Resolved  that  the  medical  inspector  be  directed  to 
have  the  15  assistant  medical  inspectors  visit  one  public 
school  each  day  in  their  respective  districts,  who  shall 
inspect  each  school  according  to  the  methods  now  em- 
ployed in  Boston,  New  York,  and  Chicago." 


Historical  25 

Since  its  first  inception  in  Boston,  the  movement  for  medical  inspec- 
tion has  rapidly  spread  in  the  United  States,  and  in  many  states  has 
developed  from  mere  inspection  for  the  detection  of  contagious  diseases 
to  systems  embracing  most  thorough  physical  examinations. 

Four  state  laws  have  been  passed.  In  1899  the  legislature  of 
Connecticut  passed  a  law  providing  for  the  testing  of  eyesight  in  all 
the  public  schools  of  the  State.  Under  this  law  the  State  Board  of  Edu- 
cation is  required  to  furnish  test-cards  and  blanks,  and  instructions 
for  their  use,  to  the  school  authorities.  The  superintendent,  principal, 
or  teacher  in  every  school  is  required  to  test  the  eyesight  of  all  the 
pupils  during  the  fall  term,  and  notify  in  writing  the  parent  or  guardian 
of  every  pupil  who  has  any  defect  of  vision,  with  a  brief  statement 
of  each  defect. 

New  Jersey  has  a  statute  which  went  into  effect  in  1903.  It  autho- 
rizes boards  of  education  to  employ  competent  physicians  as  medical 
inspectors  of  schools.  It  also  defines  the  duties  of  the  medical  inspector. 
The  law  is  permissive  and  not  mandatory  in  its  provisions. 

Vermont  followed  in  1904,  with  a  law  requiring  the  examination 
of  the  eyes,  ears,  and  throats  of  school  children  annually. 

In  1906  the  legislature  of  Massachusetts  passed  a  law  providing  for 
a  system  of  medical  inspection  throughout  the  State.  According  to 
its  provisions  every  town  and  city  must  establish  and  maintain  a  system 
of  medical  inspection  with  competent  physicians  for  the  detection  of 
contagious  diseases.  Examinations  are  conducted  annually  by  the 
physicians  for  the  detection  of  non-contagious  physical  defects,  and 
eyesight  and,  hearing  tests  are  made  each  year  by  the  teachers.  The 
law  is  mandatory,  not  permissive,  in  its  provisions. 

Without  authoritative  and  specific  enactment,  the  State  Boards  of 
Health  of  New  York,  Utah,  and  California  have  conducted  examinations 
of  the  eyesight  and  hearing  of  school  children. 

At  the  present  time — 1908 — there  are  in  operation,  so  far  as  can  be 
ascertained,  systems  of  medical  inspection  in  some  form  in  the  following 
70  cities  outside  of  Massachusetts.  (As  in  this  State  medical  inspection 
is  obligatory  under  the  state  law,  systems  exist  in  practically  every  city.) 


26 


Medical  Inspection  of  Schools 


CITIES  OF  THE  UNITED  STATES,  OUTSIDE  OF  MASSACHUSETTS, 

HAVING  SOME  FORM  OF  MEDICAL  INSPECTION 

OF  SCHOOLS,  JUNE,  1908 

City.  State.  Controlling  Authority. 

Albany New  York Albany  County  Medical  Society. 

Ann  Arbor Michigan Board  of  Education. 

Asbury  Park New  Jersey " 

Atlantic  City New  Jersey " 

Baltimore Maryland " 

Buffalo New  York " 

Camden New  Jersey " 

Chicago Illinois " 

Cincinnati Ohio " 

Cleveland Ohio " 

Dallas Texas " 

Dayton Ohio Montgomery  Co.  Medical  Society. 

Detroit Michigan Board  of  Health. 

Des  Moines Iowa Polk  Co.  Medical  Association. 

Elgin Illinois Board  of  Health. 


Health. 
It 

Education. 
Health. 


Education. 


Englewood New  Jersey " 

Evansville Indiana " 

Fort  Dodge Iowa " 

Fort  Worth Texas 

Galveston Texas " 

Grand  Rapids Michigan " 

Hackensack New  Jersey " 

Harrisburg Pennsylvania Dr. 


Education. 


Health. 


"  School  Trustees. 

"  Education  (Nurses  only). 

"  Health. 

C.  S.   Rebuck,  and  Visiting  Nurse 

Association. 

Hartford Connecticut Board  of  Health. 

Hazelton Pennsylvania Board  of  Education 

Houston Texas Houston   Association   of   Opticians  and 

Aurists. 

Jersey  City New  Jersey Board  of  Education  (Nurses  only). 

Lansing Michigan Volunteer  work 

Lincoln Nebraska 

Long  Beach California 

Los  Angeles California Boards  of  Education  and  Health. 

Milwaukee Wisconsin Milwaukee  Medical  Society. 

Minneapolis Minnesota Associated  Charities  and  Women's  Club. 

Montclair New  Jersey Board  of  Health. 

Mount  Holly New  Jersey 

Newark New  Jersey Boards  of  Health  and  Education. 

New  Haven Connecticut Board  of  Health. 

Newport Rhode  Island "       "        ' 


Historical  27 

Cities  of   the  United  States,  Outside  of  Massachusetts,  Having  Some 
Form  of  Medical  Inspection  of  Schools,  June,  1908  {Continued) 

Cm.  State  Controlling  Authority. 

New  Orleans Louisiana Board  of  Education 

New  York  City New  York "       "  Health. 

Norristown Pennsylvania 

Ogden Utah 

Orange New  Jersey Board  of  Education 

Pasadena California "       "  " 

Passaic New  Jersey "       "  " 

Paterson New  Jersey "       "  " 

Philadelphia Pennsylvania "       "  Health 

Plainfield New  Jersey "       "       " 

Port  Chester New  York 

Portland Oregon 

Providence Rhode  Island Board  of  Health. 

Reading Pennsylvania Volunteer  work 

Rochester New  York Board  of  Health. 

Salt  Lake  City Utah "       " 

San  Antonio Texas "       "Education. 

Schenectady New  York 

Seattle Washington "       "  Health. 

Sioux  City Iowa Volunteer  work. 

St.  Joseph Missouri 

St.  Louis Missouri 

Superior Wisconsin 

Syracuse New  York Board  of  Health. 

Union  Hill New  Jersey "       "  Education. 

Washington District  of  Columbia  Board  of  Health. 

Waterbury Connecticut "       "       " 

Waverly Rhode  Island 

Westchester Pennsylvania 

White  Plains New  York Board  of  Health. 

Wilmington Delaware "       "  Education 

Woonsocket Rhode  Island "       "         " 

The  work  in  Massachusetts  includes  32  cities  and  321  towns.  At 
the  beginning  of  the  present  year  it  was  reported  from  Massachusetts 
that  boards  of  health  had  begun  the  work  in  22  cities  and  47  towns 
and  boards  of  education  in  10  cities.  No  reports  were  received  from 
the  remaining  towns. 

The  foregoing  brief  account  of  the  history  of  medical  inspection 
and  its  present  status  serves  to  give  an  idea  of  the  firm  basis  on  which 


28  Medical  Inspection  of  Schools 

the  movement  rests  in  other  countries,  and  the  prominent  place  accorded 
it  in  educational  esteem.  In  America  the  movement  has  been  some- 
what tardy  in  arriving,  but  its  spread  has  been  rapid,  and  now  that 
it  has  passed  the  experimental  stage,  its  permanency  is  assured. 

Statistics  and  observation  have  shown  the  great  prevalence  of  con- 
tagious diseases  among  school  children.  Investigations  have  revealed 
the  large  percentage  of  children  suffering  from  non-communicable 
physical  defects.  Whether  or  not  the  home  is  responsible  for  a  large 
part  of  the  conditions  and  how  far  they  are  aggravated  by  the  conditions 
of  school  life  are  questions  of  ultimate  importance,  but  not  calling  for 
immediate  solution.  The  important  condition  confronting  American 
educators  and  social  workers  is  that  the  school  furnishes  an  unrivaled 
opportunity  for  detecting  and  checking  diseases  and  defects  among 
children.  The  problem  of  caring  for  those  found  to  be  defective  or 
ill,  and  of  preserving  the  health  of  those  who  are  physically  sound, 
is  one  of  the  utmost  importance.  Given  the  importance  of  the  problem 
and  the  good  examples  set  abroad,  there  can  be  no  doubt  that  rapid 
additions  will  be  made  to  the  list  of  American  cities  having  systems 
of  medical  inspection  of  schools,  and  that  those  systems  themselves 
will  rapidly  become  broader  in  scope  and  more  thorough  in  method. 


CHAPTER  IV 

Inspection  for  the   Detection  of   Contagious 

Diseases 

Nearly  all  systems  of  medical  inspection  in  America  have  had  for 
their  object  at  the  time  of  their  inception  merely  the  detection  in  their 
early  stages  of  cases  of  contagious  diseases.  To  this  simple  aim  has 
always  been  shortly  added  the  detection  and  exclusion  of  parasitic 
diseases.  Conducting  examinations  for  the  detection  of  physical 
defects  is  a  further  development  of  the  work  and  is  still  far  from  general. 

In  towns  and  small  cities  medical  inspection  for  the  detection  of 
contagious  diseases  is  a  comparatively  simple  matter  involving  few 
difficulties  in  organization  or  administration. 

In  such  places  the  teacher  who  thinks  she  sees  suspicious  symptoms 
in  one  of  her  pupils  and  fears  they  may  portend  the  beginning  of  some 
illness  notifies  the  principal  of  her  fears.  He  notifies  the  school  physician 
by  telephone  or  messenger  and  the  physician  goes  to  the  school  and 
examines  the  pupil,  sending  him  home  if  necessary.  Of  course  such 
simple  systems  require  little  in  the  shape  of  blanks  or  forms.  Notifica- 
tion cards  or  blanks  are  used  for  informing  the  parent  of  the  exclusion 
of  the  child,  and  weekly  or  monthly  reports  are  made  out  by  the  school 
physician  stating  how  many  children  he  has  examined,  how  many  he 
has  excluded  and  for  what  diseases,  and  what  other  diseases  he  has 
found  which  did  not  require  exclusion. 

A  sample  of  such  a  simple  exclusion  card  is  the  one  in  use  in  Brockton, 
Mass.  (see  p.  30). 

The  monthly  report  of  the  medical  inspector  of  the  same  city  (see  p.  3 1) 
is  also  a  good  sample  of  the  forms  found  satisfactory  in  simple  systems 
and  which  might  well  be  adapted  for  use  in  any  town  where  the  number 
of  cases  handled  is  comparatively  small  and  the  pupils  are  individually 
known  to  the  school  authorities  and  it  is  easy  to  keep  track  of  them. 

29 


30  Medical  Inspection  of  Schools 

EXCLUSION  CARD.    BROCKTON,  MASS. 

Commonwealth  of  jMassachusetts* 

CONTAGIOUS  DISEASE. 
NOTICE  TO  PARENT  OR  GUARDIAN. 

In  accordance  with  Chapter  502  of  the  Acts  of  1906,  you  are 

hereby  notified  that 

has  been  examined  by  me  as  School  Physician,  and  found  to  have 
symptoms  of 

This  child  is  excluded  from  the  schools  until  he  brings  a  state- 
ment from,  a  regular  practitioner  certifying  his  complete  recovery. 

- School  Physician. 

190 

As  systems  increase  in  size  or  it  is  found  desirable  to  make  them 
more  thorough,  difficulties  increase  and  a  more  complex  organization 
is  found  necessary.  Probably  the  most  complete  and  thoroughly 
organized  system  in  the  United  States  is  that  of  New  York  City.  While 
many  of  its  features  would  be  found  unnecessary  in  other  places,  some 
of  them  would  prove  applicable  anywhere.  It  therefore  seems  worth 
while  to  describe  it  at  some  length  and  to  give  as  well  a  brief  summary 
of  its  development  since  1897,  when  the  work  was  begun.  The  following 
account  is  largely  taken  from  the  report  of  the  Department  of  Health 
of  New  York  for  the  year  ending  December  31, 1906.  The  report  was 
published  November  30,  1907. 

THE  MEDICAL  INSPECTION  AND  EXAMINATION  OF  SCHOOL 

CHILDREN 
HISTORY 

March,  1897:  Appointment  of  one  hundred  and  fifty  Medical 
Inspectors,  at  a  salary  of  $30.00  per  month.  Morning  inspec- 
tion only  required. 

September,  1902 :    System  elaborated  to  include  morning  inspection, 


MONTHLY  REPORT  OF  MEDICAL  INSPECTOR.    BROCKTON, 

MASS. 


Q 


e 


«o 


1/1 
5 

S 

X 

5 

•siliSUiOBq 

*s9qtauoj3n 

«notSs]aoQ-uofsj 

•sasQssiQ  EnoM9f^ 

cnoiSs)uoQ-uofg 

•spiouapy 

§ 

CO 

3 

O 

u 

= 

5 

9A|)Bjnddng 

■ssmaeiQ  uijig 

••niHO'^s 

•«oa  "»1='!M0 

•"""M^-'ia 

■"i'^'A 

snoiSoiuo^ 

•Bdmny^ 

•i(Jno3  Suidooij^ 

TOJ  ll'U'S 

■JSAO  j  l»|JBDg 

•SU31)H)dl(] 

•«=I"'W 

P»pn|='q-"<i'""Nl"<'i 

z 

d 

z 

nvxox 

•S31VIM3J 

•sanvw 

1 

< 

f 


s 

2 

•ft 

O 

^ 
n 

a 

D  2 

«o 

Q  V 

V. 

U   § 

o 

u,  S 

1? 

O    o 

to 

K   CO 

S 

< 

<u 

o 

<4: 

ffl 

31 


32  Medical  Inspection  of  Schools 

routine    weekly    inspection    of    children    in    the    classrooms 

and  visiting  of  absentees  at  their  homes.     Salary  of  Inspectors 

increased  to  $100.00  per  month. 
December  i,  1902  :     Appointment  of  a  corps  of  Trained  Nurses, 

at  a  salary  of  $75.00  per  month. 
December  16, 1902  :    Establishment  of  a  Hospital  and  Dispensary 

for  the  exclusive  treatment  of  cases  of  Trachoma. 
March   27,  1905  :    Inception   of   complete   physical   examination 

of  each  school  child. 

OBJECTS 

1.  Repeated  and  systematic  inspection  and  examination  of  school 

children  to  determine  the  presence  of  infectious  or  conta- 
gious diseases. 

2.  Exclusion  from  school  attendance  of  all  children  affected  with 

acute  contagious  disease. 

3.  Subsequent  control  of  the  case,  with  isolation  of  the  patient 

and  disinfection  of  the  living  apartments  after  termination 
of  the  illness. 

4.  Control  and   treatment   of  minor   contagious   affections,   per- 

mitting the  child  to  remain  in  attendance  at  school. 

5.  Information  of  unreported  cases  of  contagious  disease  occurring 

in  school  children  at  their  homes. 

6.  Exclusion  from  school  attendance  of  those  children  in  whose 

families  there  exists  a  contagious  disease. 

7.  Complete  physical  examination  of  each  school  child  for  the  pur- 

pose of  determining  the  existence  of  non-contagious  affections 
and  advising  treatment  of  same. 

SCHOOLS  VISITED 

Public  Schools,  Parochial  Schools,  American  Female  Guardian 
Society  Schools,  Children's  Aid  Society  Schools  and  Kinder- 
gartens. 

FORCE 

1.  Assistant  Chief  Medical  Inspector,  in  charge  of  work. 

2.  Corps  of  Medical  Inspectors,  all  of  whom  are  physicians. 

3.  Supervising  Nurse,  in  direct  charge  of  the  nurses. 

4.  Corps  of  Trained  Nurses. 


Inspection  for  Detection  of  Contagious  Diseases      ^^^ 

WORKING  PLAN  OF  THE  SYSTEM 
Duties  of  Medical  Inspectors 

Each  Inspector  is  assigned  to  duty  in  a  group  of  schools 

I.  Morning  Inspection 

Inspector  visits  each  school  in  his  charge  before  ten  o'clock 
each  morning,  and  examines,  in  a  room  set  apart 
for  this  purpose,  the  following: 
(a)  All  children  isolated  by  the  teachers  as  suspected 

cases  of  contagious  diseases. 
(6)  All  children  who  have  been  absent  from  school. 

(c)  Children  returning  after  previous  exclusion. 

(d)  Children  previously  ordered  under  treatment. 

(e)  All  affected  children  referred  by  the  school  nurse  for 

diagnosis, 
(/)   All  affected  children  showing  no  evidence  of  treatment. 
Cases  to  be  Excluded 

(a)  Children  showing  signs  or  symptoms  of  smallpox, 
diphtheria,  scarlet  fever,  measles,  chicken-pox,  whoop- 
ing-cough or  mumps. 

(b)  Cases  of  pediculosis,  with  live  pediculi. 

(c)  Skin  diseases,  including  ringworm  of  scalp,  face 
or  body,  scabies,  dormant  pediculosis,  in  cases  where 
the  children  have  persistently  refused  to  imdergo 
treatment. 

Cultures  are  taken  in  all  cases  of  sore  throat  to  determine  the  presence 
of  the  diphtheria  bacillus. 

Cases  of  smallpox,  scarlet  fever  and  measles  are  reported,  by  tele- 
phone, to  the  Central  Office,  so  that  a  diagnostician  may  at  once  visit 
the  case,  confirm  the  diagnosis  and  order  isolation.  In  these  cases  a 
postal  card  is  sent  from  the  Division  of  Contagious  Diseases  to  the 
Principal  of  the  school  informing  him,  or  her,  of  the  presence  of  con- 
tagious disease,  with  instructions  that  no  member  of  the  family  be 
allowed  to  attend  school  until  the  termination  of  the  case.  The  following 
is  the  form  used: 


34  Medical  Inspection  of  Schools 

POSTAL  CARD 

department  of  Jlealtf). 

NEW  YORK  CITY. 
DIVISION  OF  CONTAGIOUS  DISEASES. 

New  York, 190 

The    following-named    children,    pupils    of    your 

school,  are  exposed  to  the  contagion  of 

at 


Sec.  145.  No  principal  or  superintendent  of  any 
school,  and  no  parent,  master  or  custodian  of  any 
child  or  minor  (having  the  power  or  authority  to  pre- 
vent) shall  permit  any  child  or  minor  having  scarlet 
fever,  diphtheria  (croup),  smallpox,  or  any  dangerous, 
infectious,  or  contagious  disease,  or  any  child  in  any 
family  in  which  any  such  disease  exists  or  has  recently 
existed,  to  attend  any  public  or  private  school  until 
the  Board  of  Health  shall  have  given  its  permission 
therefor,  nor  in  any  manner  to  be  unnecessarily 
exposed,  or  to  needlessly  expose  any  other  person 
to  the  taking  or  to  the  infection  of  any  contagious 
disease. 

Respectfully, 


Chief  Medical  Inspector. 
Reported  by 


Medical  Inspector. 

Cases  to  he  Referred  to  Their  Own  Physician,  a  Dispensary 
or  to  the  School  Nurses  for  Treatment 

(a)  Acute  conjunctivitis. 

(b)  Pediculosis. 

(c)  Skin  diseases,  including  ringworm  of  scalp,  face  or 

body,    scabies,     favus,     impetigo    and     molluscum 
contagiosum. 


Inspection  for  Detection  of  Contagious  Diseases      35 

These  children  are  re-examined  the  following  day  and  allowed  to 
attend  school  as  long  as  treatment  is  continued.  Children  affected 
with  trachoma  are  referred  to  their  own  physicians  or  to  dispensaries 
for  treatment,  and  are  allowed  to  attend  school  as  long  as  evidence  of 
treatment  can  be  shown. 

Each  excluded  child  is  furnished  with  an  ofi&cial  exclusion  card, 
properly  filled  out,  as  follows: 


EXCLUSION  CARD,  SHOWING  FACE 

DEPARTMENT  OF  HEALTH, 

BOROUGH  OF  MANHATTAN. 

New  York, 190 

Name Age 

Address 

IS    ORDERED    TO   DISCONTINUE  ATTENDANCE  at 

School  No ,  located  at 

REASON: 


Medical  Inspector. 
(see  other  side) 


EXCLUSION  CARD,  SHOWING  REVERSE 

NOTICE  TO  PARENTS. 


The  disease  mentioned  on  the  other  side  of  this  card  is  a  contagious 
affection  and  liable  to  be  transmitted  to  other  children.  The  child 
should  receive  prompt  treatment  by  any  physician  (or  at  any  dis- 
pensary), and  should  return  to  school ,  190  . . , 

for  re-examination  by  the  Medical  Inspector  of  the  Department  of 
Health.  If  found  free  from  contagion  at  this  time,  he  may  resume 
attendance  at  school. 


36  Medical  Inspection  of  Schools 

Each  pupil  referred  to  the  nurse  for  treatment  receives  from  the 
medical  inspector  a  slip  on  which  is  written  the  code  number  indicating 
the  diagnosis  of  its  affection. 


CODE  CARD,  SHOWING  NUMBERS  INDICATING  DISEASES 

Code 


I.  Diphtheria. 

12.  Varicella. 

2.  Pediculosis. 

13.  Pertussis. 

3.  Tonsillitis. 

14.  Mumps. 

4.  Pediculosis. 

15.  Zero. 

5.  Acute  Conjunctivitis. 

16.  Scabies. 

6.  Pediculosis. 

17.  Ringworm. 

7.  Trachoma. 

18.  Impetigo. 

8.  Pediculosis. 

19.  Favus. 

9.  Zero. 

20.  Molluscum  Contagiosum, 

10.  Scarlet  Fever. 

21.  Acute  Coryza 

II.  Measles. 

Cases  to  be  Readmitted 

Children  returning  after  smallpox,  scarlet  fever,  diph- 
theria, measles  and  chicken-pox  must  present  a 
certificate  from  the  Division  of  Contagious  Diseases 
before  readmittance. 

Children  returning  after  mumps  and  whooping-cough 
may  be  readmitted  at  the  discretion  of  the  Medical 
Inspector. 

2.  Routine  Inspection 

At  the  beginning  of  each  term  the  Medical  Inspector  makes  a 
routine  examination  of  each  child  in  the  schools  in  his 
charge.  The  eyelids,  throat,  skin  and  hair  of  each  pupil 
are  examined.  The  Inspector  is  not  allowed  to  touch 
the  child,  but  the  latter  is  required  to  pull  down  its  own 
eyelids,  open  its  mouth,  show  its  hands,  and,  in  the  case 
of  girls,  lift  up  her  back  hair.  Individual  wooden  tongue 
depressors  are  furnished  by  the  Department. 


Inspection  for  Detection  of  Contagious  Diseases 
INDEX  CARD 


37 


i 
Pi 

•a 

1 
s 
v 
OS 

•a 
1 

u 
H 

g 

s 

u 
H 

u 

V 

5 

ll 

o 

(0 

M 

p5 

fi 

Tf 

ui 

«■ 

t^ 

00 

» 

d 

M 

IN 

^S  Medical  Inspection  of  Schools 

All  cases  of  disease  are  recorded  on  index  cards  (see  p.  37)  with 
the  proper  data  in  appropriate  columns.  Code  numbers 
are  always  used  to  indicate  the  character  of  the  disease. 

Cases  requiring  more  extended  examination  are  sent  to  the 
Inspector's  room  at  a  definite  time  for  that  purpose. 

All  cases  of  contagious  disease  discovered  are  dealt  with  as 
indicated  in  the  description  of  Morning  Inspection. 

All  children  ordered  under  treatment  are  required  to  report  to  the 
Medical  Inspector,  at  a  definite  time,  the  following  morning  for  re- 
examination. If  treatment  has  been  instituted,  the  fact  is  recorded 
on  the  index  card,  the  child  ordered  to  report  at  regular  intervals  and, 
as  long  as  treatment  is  necessary  and  continued,  the  child  is  allowed 
to  remain  in  school.  Children  showing  no  evidence  of  treatment 
are  excluded  forthwith. 

Each  day  a  record  of  the  number  of  children  examined,  with  names, 
addresses  and  cause  of  exclusion  of  each  excluded  child,  is  mailed  to 
the  Central  OflSce.  A  duplicate  is  kept  on  file  at  the  school.  The 
following  is  the  form  of  card  used  for  this  piupose: 


INSPECTOR'S  DAILY  REPORT  OF  EXCLUSIONS 


School  No. 


MEDICAL  IJSSPECTORS  OF  SCHOOLS 

New  York, 


190. 


Examined-I  ^^     .■ 



„.         ,  *  Arrival 

Time  of  -^  T.      ._^ 

1  Dftnarture  . 





^ 

a. 

1 

s 

X 

£ 
0 

SI 
1 

s 

1 

S 

E 
s 
c 

0 

1 

e 

8 
1 

«a 

1 

M 

i 

Tout 

M 

• 

New  Cases  Found 

R 

1 

i 

M 

Casee  Excluded 

R 

Found  at  Home 

No.  of  Vaccinations  Performed.     P _ R Total 

No.  of  Physicals  Made..- No.  of  Children  Found  Defective _. 

Medical  In8x>ector 


Inspection  for  Detection  of  Contagious  Diseases      39 

3.  Absentee  Visiting 

The  Inspector  obtains  from  the  Principal  of  the  school,  each 
day,  a  list  of  all  children  who  have  been  absent  from 
school  for  several  days  for  any  unassigned  cause.  These 
children  are  visited  at  their  homes,  and  a  list  of  the  names, 
ages  and  addresses  of  all  cases  of  contagious  disease 
discovered  is  sent,  each  day,  with  the  school  report, 
to  the  Central  Office. 

Large  systems  obviously  require  somewhat  complicated  organiza- 
tions if  thorough  work  is  to  be  done.  Efficiency  and  economy  of  labor 
demand  that  printed  forms  be  used  wherever  their  use  obviates  the 
necessity  for  any  considerable  amount  of  writing,  and  the  same  consider- 
ations demand  that  on  these  printed  forms  underlining  or  checking  of 
printed  words  be  used  wherever  possible  instead  of  filling  in  of  blank 
spaces.  There  is  the  greatest  variation  in  the  practice  of  different  cities 
as  to  the  amount  of  printed  material  used.  Brockton,  Mass.,  which 
is  a  city  of  over  40,000  population,  uses  the  very  simple  blanks  described 
earlier  in  the  chapter  and  has  only  a  very  few  other  forms.     Providence, 


INSPECTOR'S  DAILY  REPORT  OF  EXCLUSIONS,  REVERSE 

EXCLUSIONS 

NAME 

AGE 

RESIDENCE 

FLOOR 

REASON 

ABSENTEES 

40  Medical  Inspection  of  Schools 

R.  I.,  has  a  blank  provided  for  almost  every  possible  need.  The  follow- 
ing is  a  list  of  the  printed  material  furnished  by  the  Providence  Board 
of  Health  as  in  use  in  connection  with  their  system  of  medical  inspection: 


PRINTED  MATERIAL  USED  IN  CONNECTION  WITH  MEDICAL 
INSPECTION  OF  SCHOOLS.    PROVIDENCE,  R.  I. 

Rules  for  teachers. 

Teacher's  note  to  School  Inspector. 

Exclusion  card. 

Post  card  report  of  case  of  contagious  disease. 

Diagnosis  card. 

Post  card  excluding  from  Sunday  School. 

Permit  to  attend  school  while  living  away  from  home. 

Permit  to  return  to  school. 

Directions  for  using  petroleum — English  and  Italian. 

Directions  for  using  white  salve — English  and  Italian. 

Directions  for  using  petroleum — English  and  Yiddish. 

Vaccination  notice. 

Post  card  excluding  pupils — diphtheria. 

Post  card  excluding  pupils — measles. 

Post  card  reporting  on  diphtheria  culture. 

Oculist  report. 

Diphtheria  exudation  report — post  card. 

Circular  to  teachers  on  referring  children  to  Medical  Inspector. 

Circular  to  teachers  on  rules  for  children. 

Rules  for  each  child. 

Notice  to  parents  on  eye  defects. 

Notice  to  parents  on  other  defects. 

Notice  to  principal  of  families  having  scarlet  fever  and  diphtheria. 

Circular  on  above. 

Directions  to  principals  on  eye  test. 

In  pursuing  the  ends  of  efficiency  and  economy  of  labor  it  is  not 
sufficient  merely  to  have  a  blank  form  for  each  necessity  that  may  arise. 
The  true  object  is  to  attain  the  desired  results  with  the  least  possible 
amount  of  clerical  work  and  this  is  especially  true  when  the  clerical 


Inspection  for  Detection  of  Contagious  Diseases      41 

work  is  to  be  performed  by  a  high-priced  man,  as  in  the  case  of  the  school 
physician. 

Let  us  consider  the  case  of  the  school  physician  who  has  examined 
a  child  referred  to  him  and  has  fovmd  him  to  have  unmistakable  symp- 
toms of  a  contagious  disease.  Some  system  is  necessary  by  which 
he  can  so  dispose  of  the  case  as  to  notify  fully  everyone  concerned. 
This  requires — 

1.  An  exclusion  notice  to  be  sent  to  the  parent, 

2.  A  record  for  the  school  authorities. 

3.  A  record  for  the  Board  of  Health. 

4.  A  record  for  himself. 

The  record  for  the  Board  of  Health  and  the  exclusion  notice  require, 
in  addition  to  the  name  of  the  child  and  the  disease,  the  name  and 
address  of  the  parent. 

Under  many  systems  these  notices  are  made  out  on  four  separate 
cards  or  sheets,  and  often  the  work  is  still  further  increased  by  having 
a  separate  card  for  the  record  of  exclusions  from  each  room  in  the  school. 
This  makes  it  necessary  to  secure  the  appropriate  card  before  the  record 
can  be  made.  Under  such  conditions  the  physician  spends  five  or  six 
times  as  much  time  in  making  entries  on  different  cards  as  he  does  in 
inspecting  the  chUd. 

A  large  part  of  this  waste  of  time  and  money  can  be  obviated  by  a 
carefully  planned  system  of  records.  In  the  case  in  point,  for  example, 
the  work  can  be  greatly  reduced  by  adapting  a  system  similar  to  the  one 
in  use  in  Chicago.  Instead  of  being  furnished  with  supplies  of  cards 
for  making  the  several  records,  each  inspector  is  supplied  with  a  book 
similar  in  size  and  shape  to  an  ordinary  check  book.  The  leaves  of 
the  book  are  alternately  of  light  and  heavy  paper  and  are  perforated 
for  separation  and  have  stubs  just  like  the  leaves  of  a  check  book.  The 
thin  leaves  and  stubs  are  printed  as  shown  on  page  42. 

The  heavy  sheet  underneath  this  is  an  exact  duplicate,  except  that 
in  the  lower  left-hand  corner,  instead  of  the  words  "Hand  to  pupil 
excluded"  it  has  the  words  "Mail  this  card  to  Chief  Medical  Inspector 
same  day  pupil  is  excluded." 

When  an  exclusion  case  is  found,  the  method  of  procedure  is  simple. 
The  inspector  inserts  a  piece  of  carbon  paper  between  the  two  sheets 


42 


Medical  Inspection  of  Schools 


EXCLUSION  NOTICE  WITH  DETACHABLE  STUB.   CHICAGO 


=  1 


-     "O 

•O    a 
1    S 


Q  vi 

©5 


2.  V 

©S 
a** 

_  © 

g  u 


3 


O        0)        w 

i  a  6 
=^  I  S 


Inspection  for  Detection  of  Contagious  Diseases      43 

and  fills  out  the  blank  and  its  stub.  The  original  blank  is  the  exclusion 
notice  and  is  taken  home  by  the  pupil.  The  stub  is  handed  to  the  school 
authorities  as  their  record  of  the  case.  The  carbon  copy  on  the  heavy 
sheet  is  torn  out  to  be  sent  to  the  Board  of  Health  as  their  notification 
of  the  case  and  the  stub  of  the  carbon  copy  is  left  in  the  book  as  the 
inspector's  record. 

At  the  conclusion  of  his  work  the  inspector  encloses  all  of  the 
carbon  copies  of  the  exclusion  notices  in  an  envelope  and  forwards  it  to 
the  Board  of  Health.  This  envelope,  besides  being  the  holder  for  the 
exclusion  notices,  is  the  daily  report  of  the  inspector.  On  its  face  are 
blanks  to  be  filled  out  as  follows: 


ENVELOPE  DAILY  REPORT   OF   MEDICAL  INSPECTOR  IN 

WHICH   ARE    FORWARDED    TO    BOARD    OF   HEALTH 

COPIES  OF  EXCLUSION  NOTICES.    CHICAGO 

CITY  OF  CHICAGO,   DEPARTMENT  OF  HEALTH 


MEDICAL    INSPECTION     OF     SCHOOLS 
Inspector's  DAILY  Report  of  Number  of  Examinations  and  Exclusions 

I  have  this  day  examined pupils  at  the 

(number) 

School,  made cultures  for  bacterial  exam- 

(number) 
ination,  performed vaccinations,  and  excluded pupils  from 

(number)  (number) 

attendance  at  school  for  reasons  stated  on  the  enclosed  exclusion  cards. 

Date, 10 M.D. 

MEDICAL  INSPECTOR 

(Place  the  Exclusion  Cards  in  this  holder,  enclose  whole  in  special  envelope  and  mail  to  Chief 
Medical  Inspector.  Report  must  be  made  EVi£RY  SCHOOLDAY,  whether  inspection  has  or  has 
not  been  made.) 


The  saving  effected  by  means  of  such  a  system  as  this  is  plainly 
seen  by  comparing  the  number  of  entries  necessary  under  the  separate 
card  method  with  the  number  required  by  the  "  check-book  and  carbon 
copy"  method. 


44  Medical  Inspection  of  Schools 

ENTRIES  NECESSARY  BY  THE  CHICAGO  METHOD  AND 
THE  CARD  METHOD 

Chicago  Method.  Separate  Card  Method. 

1.  Notice  and  Stub.  i.  Notice  to  Parents. 

2.  Envelope  Daily  Report.  2.  Record  for  school. 

3.  Record  for  Board  of  Health. 

4.  Record  for  Inspector. 

5.  Daily  Report. 

This  system  has  been  described  at  length  because  the  principle 
underlying  it  is  fundamental.  If  medical  inspectors  are  to  do  efficient 
work,  they  must  not  be  over-bvirdened  with  complex  clerical  work. 
The  aim  in  ever)^  case  must  be  the  smallest  possible  number  of  original 
entries. 

One  commendable  time-saving  device  which  has  been  adopted  in 
some  cities  is  that  of  having  the  different  cards  used  of  different  colors 
so  that  the  medical  inspector  can  put  his  hand  on  the  card  he  wants 
without  a  moment's  delay.  Utica  and  Syracuse,  N.  Y.,  have  adopted 
this  plan.  Thus,  in  Utica  the  physical  record  card  is  white;  the  notice 
to  parents  of  physical  defects,  salmon  colored;  the  exclusion  card,  buff; 
the  card  of  directions  for  ridding  the  hair  of  vermin,  pink;  and  the  card 
for  the  same  pmrpose  but  with  the  directions  printed  in  Italian  is  cherry 
color.     The  room  record  of  pupils  excluded  and  re-admitted  is  lavender. 

In  a  number  of  cities  it  has  been  fovmd  necessary  to  print  some  of 
the  cards  which  go  to  parents  in  several  foreign  languages. 

There  is  only  one  feature  which  all  American  systems  of  medical 
inspection  have  in  common.  This  is  the  supplying  of  printed  directions 
in  some  form  for  ridding  the  hair  of  vermin.  Quite  the  best  of  these 
plans  seems  to  be  that  followed  in  Everett,  Mass.,  where  the  pupil 
is  not  only  given  directions  as  to  the  treatment,  but  is  furnished  with  a 
druggist's  prescription  for  the  materials  required.  Everett  applies 
this  idea  not  only  in  the  case  of  pediculosis  (lice) ,  but  also  for  the  other 
common  complaints  of  impetigo  contagiosa,  ringworm  and  scabies. 
The  forms  used  are  reproduced  on  pages  45  and  46. 

In  nearly  all  systems  there  are  furnished  to  the  medical  inspectors 
printed    regulations    and    instructions.     While    there    is    considerable 


COMBINED  DIRECTIONS  AND  PRESCRIPTION.    EVERETT, 

MASS. 


u 

OS 

g 

T3 

O 

O 

D 

. 

^ 

^ 

tn 

fi 

• 

c! 

< 

I-I 

H 

- 

03 

< 

0) 

j:} 

Q 

"1 

-i-> 

(d 

o 

d 

>^ 

»-< 

0) 

"&! 

b 

13 

Cli 

» 

3 

< 

CQ 

u 

o 

fcb 

H 

P^ 

5^ 

cJ5 

:3 

g 

a, 
o 

■!-> 

0) 

O 

o 
o 

"tn    *j 

r^ 
C 

o 

c/5 

i-i 
o 

CJ 

(U     O 

s 

o 
;-i 

l-H 
CO 

O 

i 

O 

k4 

a 

j:3 

o 

■5 

:3  -o 

y-i 

CO 

-o 

'$ 

rt    <u 

c)o 

Oh 

g 
^ 

en 
en 
CJ 
u 

2 

'3 

-go 

.      !-i 

-w     o 

1  ^ 

^ 

!7     1J 

^ 
"o 

^ 

l-H 

-i-> 

<u  ^ 

H 

^ 

7} 

^ 

tH        -J 

U 

G 

o 

rC 

a 

<u    o 

bJD  S 

W 

^ 

^ 

o 

C  -fi 

G     O 

P^ 

JJ 

t^ 

o 

■>  "" 

c'i^ 

1— 1 

"o 

rj 

o 

c 

^    1^ 

G     >, 

P 

J-j 

CI, 

1«     a    « 

^    I-I 
.ti    o 

.22 

CJ 

en 

« 

d 

U 

CJ 

CS 

_en 

o 

"O 

H 

rs 

w 

vrj 

o 

f3 

O 

M 

lO 

lO 

3 

M 

£ 

Q 

ii 

cL 

< 

03 

G 

H 

'a^ 

a 

<1 

'§ 

en 

I-I 

o 

Ul 

pL, 

cr 

en 

en 

a> 

P< 

-5 
< 

< 

n 

o 

bb 

H 

P^ 

c75 

-G 

G 

iH 

^ 

O 

"d 

en 

a 

I-I 

< 

Ih 

-4-> 

G 

<u 

(fi 

&I 

CJ 

B 

G 

o 

c3 
.22 

'3 

o 

*o 

en 

<l 

so 

rt 
^ 

OJ 

o 

en 

Oh 
< 

.22 

T3 

o 

^ 

d 

CJ 

o 

.. 

g 

•3 

HH 

C/3 

tn 

H 

iz; 

-o 

c 

;3 

o 
1— ( 

H 
u 

pi; 

G 

)-i 

«J 

c 

G 

1—4 

£ 

cd 

Q 

•S 

45 


cfl 

03 

J3 

• 

<U 

H 

c/) 

« 

s 

O 

CO 

H 

^ 

09 

d 

d 

, 

S5 

M 

<N 

c 

D 

P 

g 

<U 

C3 

ci 

-^3 

< 

^ 

H 

o 

< 
Q 

<4-l 

O 

H 

C 

Q 

o    cu 

d 

^•4 

J3 
O 
o 

ply 
isap 

H 

< 

Oh  -a 

< 

CQ 

O 

bb 

H 

^^ 

(n 

o 

H 

o 
3 


o 

On 


c< 

Q 

< 

4) 

H 

"o 

"y 

< 

,s    w 

.b 

Cu     . 

^ 

3 

03 
>> 

3 
C/2 

pq  < 

< 

» 

o 

.SP 

H 

P^ 

^ 

(JO 

B 

cri     ciO 

rt 

^ 

o     en 

s 

o 

o  .<2 

^  .s 

.2^  — ' 

^ 

-TV  -2 

bO    3 

o    c 

^     ci 

;-l    '-^ 

^ 

■$ 
jn 

» 

-4— » 

dJ     rt 

C/) 

oj 

C3    '+-C 

i  s 

c3 

O      M 
bX)   O 

Is 

C/3 

•S    S 

o   *- 

CO 

X5     bC 

-2  ■> 

0) 

O 
I— 1 

u 

w 

a    vi 

-o   ° 

1— 1 

O      <U 

0)   U 

Q 

s    .  « 

m     u,     t! 

^  ^  3 

Inspection  for  Detection  of  Contagious   Diseases      47 

variation  as  to  detail,  these  are  in  the  main  similar  in  intent  and  provi- 
sions. They  all  provide  that  the  inspectors  shall  examine  pupils  referred 
to  him  by  the  teachers.  Some  of  them  require  in  addition  that  at  stated 
intervals  the  inspector  shall  make  a  routine  examination  of  all  the  pupils. 
In  some  places  this  is  done  once  in  tvi^o  weeks,  in  others  once  a  month 
or  once  a  term.  In  nearly  all  systems  the  inspectors  are  required 
to  examine  pupils  who  have  returned  to  school  after  several  days  of 
unexplained  absence.  In  most  places  there  is  a  provision  in  the 
regulations  to  the  effect  that  the  physician  shall  not  himself  prescribe 
for  any  pupil,  xmless  regularly  called  to  do  so  by  the  parents. 

There  is  considerable  variation  as  to  the  diseases  considered  "ex- 
cludable." In  many  places  the  rule  is  simply  to  exclude  all  cases  of 
communicable  disease.  In  other  places  specific  lists  are  given.  Some 
of  these  are  given  on  page  48. 

Where  school  nurses  are  employed  it  is  foimd  that  the  number 
of  exclusions  can  be  greatly  reduced  by  treating  many  of  the  minor 
contagious  ailments  at  the  school. 

It  is  almost  impossible  to  get  any  reliable  statistics  as  to  the  number 
of  cases  of  contagious  diseases  found  in  different  localities.  Diligent 
examination  of  all  of  the  printed  reports  obtainable  from  cities  having 
systems  of  medical  inspection  yields  very  meagre  results.  In  most 
cases  the  doctor's  report  shows  how  many  cases  of  contagious  disease 
were  found,  but  not  how  many  children  were  examined  in  finding  the 
cases.  Again,  when  the  number  of  children  examined  is  stated  it  is 
almost  always  foxmd  on  investigation  that  the  number  given  represents 
not  the  number  of  children  examined  but  the  number  of  examinations 
of  children.  Thus  the  boy  who  is  examined  ten  times  is  counted  as  ten 
children.  In  this  way  the  Board  of  Health  of  New  York  City  reported 
12,236,050  children  examined  in  1904,  when  the  average  attendance 
in  all  the  public  schools  was  only  487,000.  One  of  the  crying  needs 
of  medical  inspection  is  the  development  for  it  of  a  rational  system  of 
statistics. 


48 


Medical  Inspection  of  Schools 


en 


Pi 

EC4 


>7     1) 


oJ     .S 


s 

K 

o 

•c 

m 

c 

in 

,      «J 

o 

-1 

ja 

•         (A 

u 

o 
o 

o 

cu 

3 

_C3 

J3 

-o 

3    ::::::::   cx 


S     S     U     ^     f^     C^ 


U    U    w 


Q 

Q     o     > 
<    ^ 


P 

W 
o 


CO 
CO 

en 


»-H         cj 


3 

•c 

_U1 

tn 

D, 
C 

O 

u 

bC 

c 

ja 

•—J 

V 

S 

(U 

a 

43 

i2 

o 
o 

s  s. 


^   1    &   a^   :S 


•fr  o  I  ^  -^  ^  -S    s  .S    a    o  -^ 


:S  ^  'c  -2 
►J     1^    t;   •-•   "TS 


3 


O.     bO 

a 


.5     o     o 
2     <->    s 


•C    .2 


Q   E^   g   S 


3 


C 


g  .y  =3 


!•- 


o 
to    M 


(Z) 


o 

bO     CO 
M    M    w 


.1    E 


H   <   < 


H   <   < 


CO 

P 
O 

<3     o 

O     w 


W        03        C       •-      ^ 


i 
^  ^  I  ^ 

^       pL.       W      P^ 


XOUBER 

Number 

Per  Ci 

E.vT.  OF  Those 

Examined. 

Excluded. 

Examined,  Excluded. 

3,208 

347 

10.8 

1,424 

139 

9.8 

2,503* 

242 

9-7 

21,299 

2323 

10.9 

8,759 

1043 

12.2 

Inspection  for  Detection  of  Contagious  Diseases      49 

After  much  labor  the  following  brief  figures  as  to  exclusions  in  five 
cities  in  1907  have  been  gathered: 

EXAMINATIONS  AND  EXCLUSIONS  IN  FIVE  CITIES 


Brockton,  Mass.  (3  months) 
Lawrence,  Mass.  (3  months) 

Montclair,  N.  J 

Newark,  N.  J 21,299 

Springfield,  Mass 

About  the  only  conclusion  to  be  drawn  from  this  table  is  that  under 
common  practice  in  cities  not  employing  school  nurses  about  10  per 
cent,  of  the  children  referred  to  the  school  physician  will  be  found  to  be 
suffering  from  diseases  serious  enough  in  nature  to  warrant  their  exclu- 
sion. 

In  Massachusetts  schools  of  the  State  having  an  average  member- 
ship of  343,000  reported  during  the  school  year  1906-07  children 
suffering  from  diseases  or  defects  as  follows : 

DISEASES  AND  DEFECTS  REPORTED  IN  MASSACHUSETTS, 

1906-07 

Diphtheria 238 

Scariet  fever 313 

Measles 637 

WTiooping-cough 973 

Mumps 367 

Chicken-pox 548 

Influenza 276 

Syphilis 36 

Tuberculosis 115 

Erysipelas 17 

Adenoids 2,525 

Other  diseases  of  the  oral  and  respiratory  tract 5, 103 

Otitis 407 

Other  diseases  of  the  ear 363 

Conjuncti\'itis 779 

Other  diseases  of  the  eye 2,159 

Scabies 1,054 

Pediculosis 7,691 

Impetigo  contagiosa i ,568 

Ringworm 715 

Other  diseases  of  the  skin 1,170 

Chorea 105 

Epilepsy 41 

Deformities  (spinal  and  e.xtremities) 142 

Total  of  diseases  and  defects 27,342 

*  Average  attendance. 


50  Medical  Inspection  of  Schools 

Of  course  defects  of  vision  and  hearing  are  not  included  in  the  above 
table.  However,  even  these  incomplete  figures  show  that  the  aggre- 
gate effect  upon  school  attendance  and  school  work  is  a  subject  for  the 
most  serious  thought. 

That  the  whole  matter  of  the  relation  of  contagious  diseases  to  the 
school  life  of  children  is  one  for  serious  thought  has  been  convincingly 
demonstrated.  There  is  a  mass  of  evidence  showing  conclusively 
that  the  schools  are  a  principal  means  of  disseminating  disease  through- 
out the  community.  This  evidence  can  be  readily  secured  by  any  one. 
Pupils  are  very  apt  to  attend  schools  during  the  earlier  stages  of  diph- 
theria and  during  the  late  but  peculiarly  infectious  stage  of  scarlet 
fever,  thus  spreading  the  disease  throughout  the  community.  Medical 
inspection  greatly  reduces  this  danger.  It  is  the  testimony  of  Dr. 
Samuel  H.  Durgin,  Chairman  of  the  Boston  Board  of  Health,  that  since 
the  system  of  the  medical  inspection  of  schools  was  introduced  in  Boston, 
diphtheria  has  fallen  off  about  two-thirds  and  scarlet  fever  about  five- 
sixths.  In  the  case  of  diphtheria,  antitoxin  has  of  course  played  a 
leading  part.  In  the  case  of  scarlet  fever  the  starting  of  the  new  infec- 
tious ward  at  the  City  Hospital  has  had  an  important  effect.  But 
in  both  cases,  medical  inspection  in  the  schools  has  also  been  impor- 
tant, as  shown  by  the  fact  that  before  the  inspection  began  some  diseases, 
such  as  diphtheria,  for  instance,  were  more  common  during  the  school 
term  than  during  the  vacation  period,  but  that  after  the  inspection 
was  introduced,  they  were  less  common  during  the  school  term  than 
during  vacation. 

Again,  extensive  studies  indicate  that  over  90  per  cent,  of  the  deaths 
from  contagious  diseases,  such  as  diphtheria,  scarlet  fever,  whooping- 
cough  and  measles,  occiu"  before  the  age  of  ten. 

Contrary  to  popular  opinion,  there  is  great  mortality  from  measles 
when  this  occurs  in  the  early  stages  of  life,  and  among  the  children  of 
the  poorer  classes.  Extensive  statistics  collected  in  the  city  of  Munich 
show  that  the  mortality  from  this  disease  between  the  second  and 
fifth  year  was  4.55  per  cent.,  while  from  the  sixth  to  the  tenth  year  it 
was  only  .4  per  cent.  These  figiu-es  would  indicate  that  if  an  epidemic 
occiu"s  in  the  kindergarten  period  the  deaths  are  likely  to  be  45  in 
1000,  whereas  if  the  epidemic  can  be  postponed  until  the  primary 
school  period,  only  4  in  1000  will  die. 


Inspection  for  Detection  of  Contagious  Diseases        51 

In  the  face  of  such  evidence  as  the  above  to  argue  for  medical  in- 
spection is  to  argue  for  the  promotion  of  efficiency  in  our  schools,  the 
protection  of  the  community  and  the  preservation  of  the  lives  of  its 
children. 


CHAPTER  V 

The  Work  of  the  Teacher  in  Detecting  Con- 
tagious Diseases 

There  is  considerable  difference  of  opinion  among  physicians  hav- 
ing charge  of  systems  of  medical  inspection  as  to  whether  the  medical 
inspector  should  visit  the  school  room  only  wrhen  called  on  by  the  principal 
or  teacher,  or  whether  he  himself  should  systematically  inspect  without 
such  call.  As  the  result  of  the  non-agreement  upon  this  point  there  is, 
of  course,  wide  variation  in  practice  in  different  localities. 

Expressed  in  its  simplest  terms,  the  problem  really  resolves  itself 
into  the  question, — Is  or  is  not  the  room  teacher  competent  to  detect 
symptoms  of  disease  among  her  pupils  ? 

Among  the  important  opinions  which  may  be  cited  in  support  of 
the  contention  that  the  room  teacher  is  competent  to  detect  such  symp- 
toms are  those  of  Dr.  C.  Koon,  of  Grand  Rapids,  Mich.,  Dr.  Bert  Not- 
tingham, of  Lansing,  Mich.,  and  Superintendent  of  Schools  E.  C. 
Moore,  of  Los  Angeles,  Cal. 

Dr.  Koon,  in  speaking  of  the  Grand  Rapids  system,  says: 

"We  place  the  responsibility  of  sending  pupils  for 
inspection  on  the  teachers.  It  is  impossible  to  have  600 
or  more  pupils  examined  every  morning.  It  would  dis- 
commode school  work.  We  have  the  same  rule  as  in 
Detroit.  The  teachers  in  each  room  simply  ask  if  any 
pupils  are  feeling  sick,  and  if  so,  they  are  sent  to  the 
principal's  room.  If  any  child  is  out  of  school  for  the  day 
that  child  is  sent  to  the  principal's  room  and  examined. 
That  is  the  better  way.  The  teacher  knows  all  her  pupils 
and  knows  easily  whether  any  pupil  is  feeling  sick  by  his 
actions." 

52 


Work  of  Teacher  in  Detecting  Contagious  Diseases  53 

In  speaking  of  the  Lansing  system,  Dr.  Bert  Nottingham  says: 

"The  system  is  a  combination  of  the  Ann  Arbor  and 
Detroit  systems.  The  teachers  detect  the  cases  of  disease. 
We  hold  classes  of  instruction  with  teachers  and  show 
them  how  to  detect  these  diseases.  We  have  a  specialist 
on  eye,  ear,  nose  and  throat,  who  gives  them  information 
about  detecting  weaknesses.  Also  we  have  the  specialist 
on  eye,  ear,  nose  and  throat  as  one  of  the  inspectors." 

In  a  similar  tone,  Superintendent  E.  C.  Moore,  of  Los  Angeles, 
Cal.,  says: 

"The  best  health  officer  is  one  who  is  present  all  the 
time  and  ever  watchful  for  the  welfare  of  the  child.  That 
ever-present  health  officer  is  the  teacher." 

On  the  negative  side  of  the  question  may  be  cited  Dr.  Thomas  F. 
Harrington,  Director  of  School  Hygiene  of  Boston,  and  Dr.  Elliott 
Kent  Herdman,  Medical  Inspector  of  Schools,  Ann  Arbor,  Mich. 
In  an  address  delivered  before  the  national  meeting  of  the  Department 
of  Superintendence  of  the  National  Education  Association,  held  at 
Washington,  D.  C,  February  25-27,  1908,  Dr.  Harrington  expressed 
the  following  opinion : 

"  An  important  fact  in  the  method  of  medical  inspection 
under  the  Board  of  Health  is  that  the  detection  of  cases  of 
contagious  diseases  among  the  children  is  done  by  the 
teacher  and  not  by  the  medical  inspector;  if  the  latter  con- 
firms the  suspicion  of  the  teacher,  the  child  is  excluded  from 
school;  if  the  inspector  does  not  agree  with  the  conclusions 
of  the  teacher,  the  child  returns  to  his  classroom.  Non- 
agreement  is  very  frequent,  and  it  requires  exceptional 
perseverance  for  a  teacher  to  hazard  the  chagrin  of  a 
second  mistake,  yet  disastrous  consequences  might  result 
from  such  hesitation.  In  Boston  during  the  year  1905, 
21,111  children  were  referred  to  the  medical  inspectors; 
9,241   were  found  free  from  any  disease.     In   London 


54  Medical  Inspection  of  Schools 

between  20  and  30  per  cent,  of  the  cases  submitted  by 
the  teachers  were  not  suffering  in  any  way." 

In  a  paper  read  before  the  Ninth  General  Conference  of  Health 
Officers  in  Michigan,  Dr.  Herdman  said: 

"In  some  cities  the  inspectors  are  required  merely  to 
take  the  daily  reports  of  the  various  teachers.  I  am 
satisfied  from  my  own  experience  that  this  is  not  enough. 
A  school  teacher,  however  excellent,  is  no  more  able  to 
detect  disease  in  the  school  room  than  in  the  home,  and 
detection  is  all  important." 

"  I  go  into  the  schoohroom  and  sit  down  to  familiarize 
myself  with  the  faces  of  the  pupils.  After  a  few  times, 
they  have  become  used  to  it  and  I  can  detect  anything 
wrong.  I  think  the  doctor  should  go  into  the  schoolroom 
at  least  once  a  week.     The  teachers  simply  cannot  detect." 

Despite  the  radically  contradictory  nature  of  these  opinions,  the 
problem  has  been  solved  satisfactorily  in  many  localities.  The  solu- 
tions are  in  the  nature  of  compromises  between  the  system  of  relying 
entirely  on  the  teacher  for  detecting  symptoms  of  disease  and  that  of 
insisting  that  the  doctor  alone  shall  make  the  inspection. 

It  is  the  verdict  of  experience  that  three  general  propositions  hold 
true:  First,  it  is  impracticable  to  have  the  doctor  inspect  all  the  children 
every  day.  Second,  he  should  see  them  all  sometimes.  In  some 
systems  such  routine  inspections  of  all  pupils  are  made  once  in  two 
weeks,  in  others  once  a  month,  and  in  still  others  once  a  term.  Third, 
where  school  nurses  are  employed  the  problem  largely  disappears, 
as  the  teacher  and  the  niu-se  together  readily  decide  which  pupils  should 
go  to  the  inspector. 

In  localities  where  systems  have  been  carefully  worked  out,  teachers 
are  provided  with  printed  directions  as  to  the  symptoms  which  they 
should  notice  and  on  account  of  which  children  should  be  referred  to 
the  school  physicians.  Probably  the  most  carefully  worked  out  set 
of  such  instructions  is  that  given  in  the  pamphlet  issued  by  the  Mass- 
achusetts State  Board  of  Education,  containing  suggestions  of  teachers 


Work  of  Teacher  in  Detecting  Contagious  Diseases  55 

and  school  physicians  regarding  medical  inspection.  This  little  book 
so  well  fills  the  need  that  it  has  been  reprinted  for  use  in  many  other 
localities.  It  is  such  a  good  example  of  what  such  a  manual  should  be 
that  it  has  seemed  well  to  reprint  it  in  its  entirety  in  this  volume.  It  will 
be  found  as  Appendix  I.  Under  the  heading,  "  Some  General  Symptoms 
of  Disease  in  Children  which  Teachers  should  Notice,  and  on  Accoimt 
of  which  the  Children  should  be  Referred  to  School  Physician,"  it 
gives  explanatory  directions  under  each  of  the  following  headings: 

Emaciation, 

Pallor, 

Puffiness  of  the  face, 

Shortness  of  breath, 

Swellings  in  the  neck. 

General  lassitude  and  other  evidences  of  sickness, 

Flushing  of  the  face, 

Eruptions  of  any  sort. 

Cold  in  the  head  with  running  eyes. 

Irritating  discharge  from  the  nose, 

Evidence  of  a  sore  throat. 

Coughs, 

Vomiting, 

Frequent  requests  to  go  out. 

In  the  Annual  Report  of  the  Superintendent  of  Schools  of  Albany 
for  1907  is  found  a  list  of  symptoms  for  which  teachers  are  required 
to  refer  children  to  the  inspector.  The  list  is  not  very  different  from 
that  used  in  Massachusetts.     It  is  as  follows: 

ALBANY  LIST 

Unusual  pallor. 

Unusual  dullness  or  sleepiness, 

Red  or  discharging  eyes, 

Reddened  or  discharging  ears, 

Deafness, 

Discharge  from  the  nose. 

Mouth-breathing, 

Enlarged  glands  in  the  neck, 


56  Medical  Inspection  of  Schools 

Swelling  of  neck  at  angle  of  jaw, 

All  skin  eruptions, 

Constant  scratching  of  any  part  of  the  body, 

Children  who  maintain  peculiar  postures  at  the  desk. 

Children  showing  defective  vision  of  either  or  both  eyes, 

Children  returning  to  school  with  excuse  alleging  illness  and 

without  note  from  attending  physician. 
Children  returning  to  school  or  attending  regularly  and  living 

at  the  same  time  in  houses  in  which  there  is,  or  has  recently 

been,  illness. 
Children  asking  frequent  permission  to  go  to  the  toilet. 

Providence,  R.  I.,  Syracuse  and  White  Plains,  N.  Y.,  also  furnish 
the  teachers  with  similar  printed  directions.  Providence,  however, 
goes  farther  than  this.  There  each  teacher  is  furnished  with  a  slip  of 
paper  to  be  pasted  in  her  roUbook,  where  it  will  always  serve  for  ready 
reference  and  as  a  constant  reminder.  This  slip  contains  the  following 
rules: 


RULES  FOR  CONTAGIOUS  DISEASES,  PROVIDENCE,  R.  I. 
RULES  FOR  CONTAGIOUS  DISEASES. 


The  Teacher  will  please  paste  this  in  the  register  book. 


Children  with  the  following  diseases  must  be  kept  out  of  School: 

With  chicken-pox  until  the  crusts  are  all  off. 
With  mumps  two  weeks,  and  longer  if  the  glands  are  tender. 
With  whooping  cough  while  the  child  whoops. 
With  German  measles  for  two  weeks. 

With  measles  until  two  weeks  from  the  beginning  of  the 
sickness. 

When  there  is  measles  in  a  family,  children  who  have  previously 
had  it  may  be  allowed  in  school.  Those  who  have  not  had  it  must  be 
excluded  for  two  weeks  from  the  beginning  of  the  last  case. 

Permits  are  not  necessary  for  any  of  the  above.  The  teacher  can 
usually  determine  the  duration  of  the  sickness  better  than  the  medical 
inspector. 

All  children  living  in  houses  where  there  is  diphtheria,  scarlet 
fever  or  small-pox  must  be  excluded  from  school  until  they  present  a 
permit  from  the  health  department. 


Work  of  Teacher  in  Detecting  Contagious  Diseases  57 

Moreover,  each  teacher  is  furnished  with  a  supply  of  sheets  of 
paper  on  which  are  printed  in  simple  language  rules  to  be  observed 
by  the  pupils  and  which  the  teacher  is  expected  to  teach  and  enforce. 
A  copy  is  given  to  each  child. 

PRINTED  RULES  DISTRIBUTED  TO  ALL  PUPILS 
IN  PROVIDENCE,  R.  I. 

REMEMBER  THESE  THINGS. 

Do  not  spit  if]  you  can  help  it.  Never  spit  on  a  slate,  floor,  or 
sidewalk. 

Do  not  put  the  fingers  into  the  mouth. 

Do  not  pick  the  nose  or  wipe  the  nose  on  the  hand  or  sleeve. 

Do  not  wet  the  finger  in  the  mouth  when  turning  the  leaves  of  books. 

Do  not  put  pencils  into  the  mouth  or  wet  them  with  the  lips. 

Do  not  put  money  into  the  mouth. 

Do  not  put  pins  into  the  mouth. 

Do  not  put  anything  into  the  mouth  except  food  and  drink. 

Do  not  swap  apple  cores,  candy,  chewing  gum,  half  eaten  food, 
whistles  or  bean  blowers  or  anything  that  is  put  in  the  mouth. 

Never  cough  or  sneeze  in  a  person's  face.  Turn  your  face  to  one 
side. 

Keep  yoiu:  face  and  hands  clean;  wash  the  hands  with  soap  and 
water  before  each  meal. 

Another  feature  of  the  Providence  system  is  that  the  principals 
are  furnished  by  the  Department  of  Health  with  printed  lists  of  the 
families  of  the  city  in  which  scarlet  fever  or  diphtheria  has  been  reported, 
to  the  end  that  children  living  at  locations  named  on  the  list  may  be 
excluded  from  school  imtil  permits  for  their  return  are  furnished  by  the 
department. 

The  city  of  Wilkesbarre,  Pa.,  goes  even  farther  than  does  Provi- 
dence, R.  I.,  in  the  matter  of  giving  each  pupil  a  set  of  simple  health 
rules.  The  scheme  is  rather  novel.  The  school  board  has  adopted 
six  simple  rules  for  promoting  health.  They  are  to  be  printed  on  the 
cover  of  every  book  used  in  the  public  schools.     Here  they  are: 


58  Medical  Inspection  of  Schools 

1.  Fresh  air  and  sunshine  are  necessary  to  good  health. 

2.  Night  air  is  as  good  as  day  air,  and  in  cities  where  there  is  much 

dust,  better. 

3.  Eat  little  fried  food,  pastry,  candy,  cake,  and  sugar, 

4.  Wash  your  hands  before  you  eat. 

5.  Never  lick  your  fingers  when  t\iming  pages  or  when  counting 

money. 

6.  Avoid   spitting   because    it    promotes    consumption    and    other 

diseases. 

There  are  several  plans  by  which  the  teacher  refers  to  the  school 
physician  the  children  she  believes  to  show  symptoms  of  some  illness. 
The  simplest  and  perhaps  the  most  common  is  for  the  teacher  to  send 
the  children  to  the  principal's  or  the  school  physician's  room  without 
any  note  as  to  what  trouble  she  suspects  or  any  particulars  as  to  the 
case.  There  are  good  reasons  why  this  system  is  not  satisfactory.  Some 
of  them  are  well  stated  by  Dr.  S.  W.  Newmayer,  of  Philadelphia,  in 
"A  Practical  System  of  Medical  Inspection  with  Trained  Nurses, 
Adapted  for  Public  Schools  of  Large  Cities."     Dr.  Newmayer  says: 

"Each  morning  the  teacher  fills  out  for  each  pupil  she 
desires  examined  by  the  inspector  that  part  of  the  card 
above  the  dotted  line.  This  may  seem  as  though  more 
clerical  work  is  being  shifted  on  the  already  overworked 
teacher.  But  a  moment's  reflection  will  prove  it  saves  her 
time,  trouble,  and  responsibility.  Many  of  the  younger 
pupils  do  not  know  their  name,  address,  and  nimiber  of 
classroom,  much  less  why  the  teacher  sent  them  to  the 
doctor.  This  necessitates  the  return  of  the  pupil  to  his 
class  with  a  note  requesting  the  desired  information, 
which  is  eventually  written  on  any  scrap  of  paper,  to  again 
be  copied  by  the  doctor,  and  a  third  time  by  the  nurse. 
I  have  heard  teachers  say, '  Who  wishes  to  go  to  the  doctor  ? ' 
There  are  a  few  shiftless  pupils  who  are  only  too  ready 
to  accept  such  an  invitation  to  get  out  of  the  classroom. 
With  the  teacher  answering  the  question,  'Why  sent  to 
medical  inspector?'  this  imposition  is  avoided." 


Work  of  Teacher  in  Detecting  Contagious  Diseases  59 

A  good  specimen  of  a  very  simple  card  from  the  teacher,  requesting 
the  inspector  to  examine  a  child,  is  that  used  in  the  Providence,  R.I., 
schools. 


TEACHER'S  REQUEST  TO  INSPECTOR,  PROVIDENCE,  R.  I. 

Note  to  School  Inspector. 

Name 

Residence 

School 

Please  examine  this  pupil  for 

Teacher. 

When  out  of  Blanks  notify  Health  Department. 

A  card  providing  for  a  fuller  statement,  and  in  many  ways  a  better 
one,  is  in  use  in  the  schools  of  Asbury  Park,  N.  J.  It  is  a  standard 
4x6  inch  filing  card  and  has  the  advantage  of  insuring  future  ready 
reference  when  filed  in  a  card  index  drawer. 


CARD  OF  REQUEST  TO  INSPECTOR,  ASBURY  PARK,  N.  J. 
ASBURY  PARK  PUBLIC  SCHOOLS. 

DEPARTMENT  OF  MEDICAL  INSPECTION. 


0 
0 

X) 
u     . 

Date 

Name  of  pupil 

This  C 
when  ai 
should 

Residence 

c;  3  SB 

to    lU 

Age                                                                Class 
Any  cases  of  sickness  at  home  ? 

is  to  be  fi 
)upil  appe 
n  be  sent 

lied  ov 
ars  to  1 
to  the 

Symptoms  noted  by  teacher  : 

G  CO 

2:.^ 

ythet 
11.  Th 
tor's  d 

-23 

eacher 
s  card 
esk. 

Teacher. 

6o  Medical  Inspection  of  Schools 

REQUEST  OF  TEACHER  AND  STATEMENT  BY  INSPECTOR, 
WASHINGTON,  D.  C. 

FORM  A. 

ORIGINAL. 

HEALTH  DEPARTMENT. 
MEDICAL  INSPECTION  OF  PUBLIC  SCHOOLS. 

Hour  * Date 190  . 

School  Building.     Room  No 

REQUEST  FOR  MEDICAL  INSPECTION. 

Will  the  Medical  Inspector  please  examine 

,     residing  at 

to  determine  the  advisability  (i)  *  of  exclusion  on  account  of  contagious 
disease;  (2)  *  of  exclusion  on  account  of  non-contagious  disease; 
(3)  *  of  readmission. 


Signature  of  Teacher. 


*  When  inserting  hour,  state  whether  "a.  m."  or  "p.  m." 

*  Check  whichever  phrase  indicates  the  purpose  of  the  proposed  inspection. 


RESULT  OF  INSPECTION. 

Date  of  inspection ,  190     .     Hour. 

Tentative  diagnosis 

*  Recommendations 


Signature  of  Medical  Inspector. 

*  If  exclusion  is  recommended,  specify  the  section  of  the  regulations  under  which  such 
action  is  to  be  taken.  If  duration  of  proposed  exclusion  is  not  determined  by  these  regulations, 
specify  the  duration  thereof. 


Work  of  Teacher  in  Detecting  Contagious  Diseases  6i 


FORMA. 

DUPLICATE. 

HEALTH  DEPARTMENT. 
MEDICAL  INSPECTION  OF  PUBLIC  SCHOOLS. 

Hour* Date igo  . 

School  Building.     Room  No 

REQUEST  FOR  MEDICAL  INSPECTION. 

Will  the  Medical  Inspector  please  examine 

,     residing  at 

to  determine  the  advisability  (i)  *  of  exclusion  on  account  of  contagious 
disease;  (2)  *  of  exclusion  on  account  of  non-contagious  disease; 
(3)  *  of  readmission. 


Signature  of  Teacher. 

*  When  inserting  hour,  state  whether  "a.  m."  or  "p.  m." 

*  Check  whichever  phrase  indicates  the  purpose  of  the  proposed  inspection. 


RESULT  OF  INSPECTION. 

Date  of  inspection ,  190     .     Hour . 

Tentative  diagnosis 

*  Recommendations 


Signature  of  Medical  Inspector. 

*  If  exclusion  is  recommended,  specify  the  section  of  the  regulations  under  which  such 
action  is  to  be  taken.  If  duration  of  proposed  exclusion  is  not  determined  by  these  regulations, 
specify  the  duration  thereof. 


62  Medical  Inspection  of  Schools 

A  third  card  of  notification  is  a  slip  iiaving  space  provided  for  the 
teacher's  statement  regarding  the  child  and  the  physician's  diagnosis 
and  disposition  of  the  case.  Such  a  slip  is  in  use  in  the  schools  of 
Somerville,  Mass. 


STATEMENTS    OF   PHYSICIAN   AND    TEACHER, 
SOMERVILLE,  MASS. 

No.  s) 

190. 

KEEP  ON  FILE 


TEACHER'S  STATEMENT 

{Name) Room  No 

School 

Complaint 

PHYSICIAN'S  STATEMENT 

Diagnosis 

Advice 


The  same  plan  is  followed  in  Washington,  D.  C,  but  with  a  some- 
what more  complex  blank  and  one  possessing  the  additional  feature 
of  being  so  made  as  to  provide  for  fiUing  out  at  the  same  time  an  original 
and  a  duplicate  copy.  With  this  plan,  one  copy  can  be  kept  on  file 
in  the  school  and  the  other  sent  to  the  office  of  the  Health  Department ; 
or  one  copy  can  be  kept  by  the  school  physician  and  the  other  by  the 
room  teacher. 


Work  of  Teacher  in  Detecting  Contagious  Diseases  63 

There  are  points  in  favor  of  each  one  of  the  systems  described. 
A  plan  which  unites  in  one  simple  system  the  greatest  number  of  these 
points  is  that  described  by  Dr.  Newmayer  in  the  paper  above  referred 
to.  He  advocates  the  use  of  a  card  of  which  the  following  is  a  repro- 
duction. 


CARD  USED  BY  DR.  NEWMAYER  IN  PHILADELPHIA,  PA. 


School Teacher Room  No 

Name Address 

Date Sent  to  Medical  Insp.  for 

Diagnosis 

Referred  to  physician — Dispensary — Nvirse. 

Excluded — date Retvirned 

Treatment  by  nurse — at  home — at  school. 
Dates  of  treatment — 
Results — Cured 

Improved 
Not  improved 

Medical  Inspector. 
Total  number  treatments — 

Nurse. 


The  system  is  devised  for  use  in  localities  where  trained  nurses  are 
employed  and  is  based  on  using  but  one  card  and  one  blank.  Each 
morning  before  beginning  the  day's  exercises  each  teacher  goes  through 
her  class  and  notes  the  pupils  she  wishes  to  send  to  the  principal.  Each 
child  is  given  one  of  the  cards  on  which  the  teacher  has  filled  in  the  three 
lines  at  the  top,  giving  the  school,  the  name  of  the  teacher,  the  number 
of  the  room,  the  name  and  address  of  the  child,  the  date,  and  the  teacher's 
reason  for  sending  the  child  to  the  inspector.  On  these  cards  the  in- 
spector underscores  whether  the  pupil  is  to  go  to  the  niu^e,  dispensar\', 
or  family  physician  for  treatment;  or  whether  excluded  from  the  class. 
Each  pupil  sent  to  the  inspector  for  examination  receives  one  of  the 
following  slips  to  take  back  to  his  teacher: 


64  Medical  Inspection  of  Schools 


To  Teacher: — 

This  child  is  referred  for  treatment  to 

NURSE 
DISPENSARY 
FAMILY  PHYSICIAN 

This  child  is excluded  from  the  classroom 

until  you  receive  notice  for  his  (her)  return. 

Medical  Inspector. 


This  admits  of  no  mistake  by  the  teacher  and  aids  her  in  knowing 
the  exact  nature  and  disposition  of  each  case.  The  child  cannot  go 
home  for  the  remainder  of  the  day  if  he  has  been  instructed  to  wait 
for  treatment  by  the  nurse,  and,  again,  a  child  excluded  cannot  return 
to  his  seat  in  the  classroom  and  the  teacher  remain  ignorant  of  his 
exclusion  by  the  inspector.  It  admits  of  the  principal  having  a  full, 
written  record  of  the  disposition  of  all  cases  sent  to  the  inspector. 

When  the  case  is  referred  to  the  nurse,  the  inspector  specifies  on 
the  card  if  the  child  is  to  be  treated  at  home  or  at  school,  or  both;  also 
the  treatments  recommended.  This  concise  written  report  makes 
mistakes  impossible  and  may  prove  valuable  if  legal  or  other  questions 
arise. 

These  cards  are  filed  in  the  office  in  a  box  with  three  compartments : 
first,  "New  cases";  second,  "Unfinished  cases";  third,  "Cured  cases." 
Each  of  these  compartments  is  arranged  according  to  the  number  of 
classrooms.     Dr.  Newmayer  states : 

"The  nurse,  on  visiting  the  school,  first  takes  all  cards  in 
the  compartment  of  new  cases,  and  sends  for  each  pupil 
individually.  The  information  on  the  card  makes  it 
possible  for  her  to  perform  all  her  work  without  troubling 
the  principal  or  teachers.  After  attending  to  the  new 
cases  and  recording  on  them  the  date  of  treatment,  she 
replaces  them  in  the  cabinet,  in  the  compartments  of  un- 
finished or  cured  cases.  She  now  looks  over  the  unfinished 
cases  and  sends  for  those  requiring  treatment,  again  re- 


Work  of  Teacher  in  Detecting  Contagious  Diseases  65 

cording  the  date.  She  so  proceeds  each  day  until  the 
child  is  cured  or  disposed  of,  when  she  records  the  date 
of  cure,  when  the  card  is  filed  in  the  third  compartment. 
Once  a  month  all  finished  cards  are  sent  to  the  Bureau 
of  Health  or  Bureau  of  Education,  where  they  are  filed  in  a 
cabinet  according  to  school  and  disease.  One  can  readily 
see  how  easy  it  would  be  to  refer  to  these  records.  For 
example,  should  one  desire  to  know  how  many  cases  of 
defective  vision  were  treated  and  obtained  the  necessary 
glasses,  or  the  average  number  of  treatments  required 
at  school  to  cure  a  certain  skin  disease,  these  facts  can 
readily  be  obtained." 

Each  week  the  nurse  makes  out  a  report  of  her  work,  which  is 
forwarded  to  the  chief  medical  inspector.  A  reproduction  of  the 
blank  used  will  be  found  on  page  78  in  the  chapter,  "The  School 
Nurse."  It  is,  of  course,  evident  that  the  system  described,  using  only 
one  card  and  having  a  slip  returned  to  the  teacher,  telling  what  disposi- 
tion the  school  physician  has  made  of  the  case,  is  just  as  applicable 
to  systems  where  nurses  are  not  employed. 

From  the  viewpoint  of  efficiency  it  is  a  much  mooted  question  whether 
teachers  should  or  should  not  have  the  duty  of  attempting  to  detect 
signs  of  illness  among  the  children.  In  established  systems  this  question 
is  a  very  real  problem  of  administration  and  is  probably  best  solved 
by  such  a  compromise  as  was  described  earlier  in  this  chapter.  In 
places  where  systems  of  medical  inspection  do  not  exist  and  where 
their  establishment  depends  on  making  a  simple  and  inexpensive  begin- 
ning the  problem  disappears.  Conditions  inevitably  resulting  in  disaster 
to  the  physical  well-being  of  the  pupils  exist  in  our  schools  as  a  con- 
sequence of  grouping  together  children  from  all  sorts  of  homes,  from 
families  of  all  sorts  of  standards  of  cleanliness  and  health.  Under 
these  circumstances  the  important  thing  is  to  construct  the  social  ma- 
chinery to  deal  with  the  problem  that  confronts  us.  The  teacher,  being 
present,  available,  and  in  direct  contact  with  the  children,  is  the  one 
to  whom  we  must  look  as  the  agency  for  the  initial  starting  of  the 
machinery. 
5 


CHAPTER  VI 

The  School  Nurse 

Dr.  S.  W.  Newmayer,  of  Philadelphia,  terms  the  school  nurse  "the 
most  important  adjunct  to  medical  inspection."  Dr.  John  J.  Cronin, 
of  New  York,  in  writing  of  the  work  of  the  school  nurse  in  that  city, 
says:  "Instead  of  opposition  to  this  work  at  school,  it  is  most  highly 
endorsed  by  teachers,  principals,  educators,  parents,  and  children. 
Since  this  innovation  many  cities  throughout  the  world  have  copied 
our  nursing  system  as  far  as  possible,  up  to  the  standard  set  by  this 
city."  Dr.  Ernest  J.  Lederle,  formerly  Commissioner  of  Health  of 
New  York  City,  says,  "The  school  nurse  has  been  voted  a  success 
from  the  day  she  began  work."  Dr.  Walter  S.  Cornell  says  of  the  school 
nurses  in  Philadelphia,  "As  a  rule,  in  the  foreign,  poverty-stricken 
sections  they  are  invaluable."  Dr.  Thomas  F.  Harrington,  Director 
of  the  Department  of  School  Hygiene  of  Boston,  writes,  "  It  does  not 
seem  possible  to  conceive  a  more  satisfactory  arrangement  or  a  more 
effective  piece  of  school  machinery  than  the  school  nurse  under  school 
supervision." 

Citations  from  the  best  authorities  on  the  subject,  similar  in  tone 
to  those  quoted,  might  be  indefinitely  multiplied.  It  may  be  said  indeed 
that  there  is  no  division  of  opinion  on  the  subject.  The  leading  authori- 
ties without  exception  advise  and  recommend  school  nurses  in  con- 
nection with  the  work  of  medical  inspection. 

Although  this  feature  of  the  work  is  recognized  as  being  so  im- 
portant, its  development  in  America  has  been  comparatively  recent. 
The  first  regular  employment  of  trained  nurses  in  connection  with  the 
work  of  medical  inspection  seems  to  have  been  in  December,  1902, 
in  New  York  City,  when  a  corps  of  nurses  was  established  at  a  salary 
of  $75.00  each  per  month.  Previous  to  this  the  experiment  had  been 
tried  in  a  small  way,  but  with  great  success,  in  London.  The  success 
of  the  experiment  was  immediate  and  the  movement  has  spread  rapidly. 

66 


The  School  Nurse  67 

New  York  still  maintains  the  corps  of  trained  nurses.  Philadelphia 
and  Boston  have  them.  Baltimore,  Los  Angeles,  Grand  Rapids, 
New  Haven,  Orange,  N.  J.,  and  Syracuse  and  Yonkers,  N.  Y.,  are 
among  the  other  cities  employing  school  nurses. 

Indeed,  experience  has  proved — especially  in  the  largest  cities,  where 
systems  of  medical  inspection  have  been  in  operation  some  time — that 
the  employment  of  competent  school  niu-ses  is  almost  a  necessity.  This 
comes  to  light  first  in  dealing  with  the  cases  of  children  who  have  been 
excluded  for  minor  contagious  diseases.  A  child  who  has  been  sent 
home,  say  for  pediculosis,  receives  no  attention  from  his  parents.  After 
a  few  days'  absence  he  returns  to  school  in  the  same  condition  in  which 
he  left.  This  process  may  be  repeated  several  times  before  the  child  is 
finally  put  into  fit  condition  for  resuming  his  school  work.  The  result 
is  that  when  he  does  return,  he  is  behind  in  his  studies;  and  while  he 
has  been  absent,  the  city  has  been  paying  for  his  instruction  and  no 
instruction  has  been  received.  Such  cases  as  this  are  typical  and  numer- 
ous. Again,  there  are  many  simple  cases  of  minor  ailments  which, 
properly  treated  by  the  nurse  in  school,  will  not  prevent  the  regular 
attendance  of  the  child.  Where  such  treatment  is  not  possible,  they 
compel  his  temporary  exclusion.  In  many  other  cases  the  school 
nurse,  by  visiting  the  home  and  conferring  with  the  parents,  secures 
treatment  of  some  ailment  by  the  family  physician  which  in  the  absence 
of  such  home  visiting  would  be  neglected. 

Such  considerations  as  this  played  a  large  part  in  bringing  about 
the  establishment  of  the  first  regular  corps  of  trained  nurses  for  work 
in  the  public  schools.  As  before  stated,  this  was  in  New  York  in  1902. 
Previous  to  that  time  there  had  been  a  system  of  medical  inspection 
in  operation  for  some  eight  years.  Before  the  nurse  began  work  it  was 
found  that  many  of  the  children  that  were  excluded  on  account  of 
contagious  diseases  received  no  home  care  whatever.  The  parents 
either  failed  to  understand  the  printed  card,  or  ignored  it  altogether. 
The  child,  instead  of  being  attended  to,  was  left  to  play  in  the  street, 
and  associated  with  the  other  children  as  they  came  out  of  school, 
thereby  coming  in  contact  with  them  almost  as  much  as  if  he  had  re- 
mained in  school.  Contagion  was  not  being  greatly  lessened  in  the  com- 
munity; the  child  was  not  receiving  medical  attention,  but  was  losing  his 
schooling. 


68  Medical  Inspection  of  Schools 

That  the  employment  of  competent  school  nurses  very  greatly  reduces 
the  number  of  exclusions  from  school  was  conclusively  proved  by  the 
experience  in  New  York  before  and  after  their  employment.  For 
the  quarter  ending  December,  1902,  we  have  the  following  table  of 
exclusions  from  the  New  York  public  schools: 

Measles 18 

Diphtheria 140 

Scariet  Fever 13 

Whooping  Cough 61 

Mumps 9 

Trachoma 12,647 

Pediculosis 8,994 

Chicken-pox 172 

Skin  Diseases 661 

Miscellaneous i  ,823 

Total 24,538 

During  this  time  there  were  sixteen  diseases  which  were  excluded. 
The  corps  of  nurses  was  organized  in  December.  A  card  index  system 
was  installed  by  which  an  absolute  record  of  every  case  of  contagious 
diseases  in  the  schools  could  be  kept,  together  with  the  dates  of  treat- 
ment and  termination.  Under  this  system  the  number  of  excludable 
diseases  was  limited  to  seven.  These  when  found  must  be  excluded 
at  once.     They  are: 

Diphtheria  Pertussis 

Scarlet  Fever  Mumps 

Measles  Acute  Coryza 
Varicella 

It  will  be  readily  seen  that  had  this  system  been  in  use  during  the  quarter 
ending  December  31,  1902,  there  would  have  been  the  following  ex- 
clusions only: 

Measles 18 

Diphtheria 140 

Scarlet  Fever 61 

Mumps 9 

Chicken-pox 172 

Total 460 


The  School  Nurse  69 

In  other  words,  the  number  of  exclusions  under  the  old  system  of 
medical  inspection,  without  the  careful  card  record  and  trained  nurses, 
was  24,538.  After  the  installation  of  the  card  system  and  the  employ- 
ment of  the  nurses,  this  number  would  have  been  reduced  to  400. 
The  difference,  representing  the  number  of  pupils  who,  although  suf- 
fering from  some  minor  contagious  ailment,  are  allowed  under  the  new 
system  to  continue  in  school,  is  24,138.  In  addition  it  has  been  found 
necessary  to  add  to  this  list  cases  of  pediculosis,  with  live  pediculi, 
and  contagious  skin  diseases  where  the  pupil  has  persistently  refused 
to  undergo  treatment.  While  these  additions  reduce  to  some  extent 
the  proportion  of  those  who  are  allowed  to  continue  in  school,  it  still 
remains  true  that  the  number  of  exclusions  since  the  installation  of  the 
card  system  and  the  employment  of  the  nurses  has  been  immensely 
reduced. 

A  good  idea  of  what  may  be  accomplished  by  the  trained  nurse 
in  the  public  schools  is  given  by  Dr.  S.  W.  Newmayer,  of  Philadelphia, 
in  a  paper  read  at  a  meeting  of  the  Medical  Society  of  Pennsylvania, 
September  11-13,  1906.  He  describes  the  work  of  one  nurse.  Miss 
Annie  L.  Stanley,  who  was  loaned  to  the  city  of  Philadelphia  by  the 
Visiting  Nurse  Society  to  show  the  great  value  of  the  trained  nurse  in 
the  medical  inspection  of  schools. 

In  April,  1904,  the  schools  of  the  Fourth  Section,  five  in  nvmiber, 
were  assigned  to  the  nurse.  A  well-organized  system  was  worked 
out  and  closely  followed.  The  nurse  visited  the  schools  daily,  three 
in  the  morning  session  and  two  in  the  afternoon.  The  medical  inspec- 
tor diagnosed  and  excluded  from  the  school  cases  of  contagion  and 
recommended  for  treatment  children  suffering  from  various  ailments. 
Written  instructions  as  to  the  disposal  of  each  case,  treatment  recom- 
mended, and  whether  the  case  was  to  be  visited  by  the  nurse  at  its 
home,  were  left  at  the  office  of  the  principal.  The  nurse  each  day 
obtained  from  this  office  the  instructions.  She  followed  up  each  case 
and  saw  that  the  instructions  and  recommendations  of  the  physician 
were  brought  to  a  speedy  and  successful  termination.  In  each  school 
a  small  room  was  set  aside  for  the  work  of  the  nurses.  Here  she  had  a 
drug  closet  and  all  requisite  supplies.  WTien  necessary,  she  visited 
the  homes  of  the  children  to  give  treatment  and  instructions,  and  ob- 
tained the  cooperation  of  parents,  thereby  assuring  success  and  more 


70  Medical  Inspection  of  Schools  ' 

permanent  results.  Sometimes  circumstances  made  it  necessary  for 
the  nurse  to  personally  take  a  child  to  the  dispensary  for  treatment. 
These  home  and  dispensary  visits  were  made  after  school  hours  and 
on  Saturdays.  There  were  various  problems  to  be  solved  in  each 
case,  and  the  nurse  invariably  found  the  remedy.  The  duties  of  the 
school  nurse  assured  success  to  the  work  of  the  medical  inspector  in 
improving  the  health  of  the  school  children.  She  lessened  the  number 
of  exclusions  from  the  classroom  for  minor  contagious  diseases.  She 
saw  that  all  excluded  cases  were  placed  under  treatment  as  soon  as 
possible,  so  that  there  should  be  the  least  possible  loss  of  time  from 
school  and  education.  She  treated  those  cases  which  would  for  various 
reasons  receive  no  attention  at  their  homes.  The  medical  inspector 
recognized  and  excluded  from  the  school  cases  of  contagion,  and  recom- 
mended for  treatment  children  suffering  from  defects  hindering  them  in 
their  studies.  These  cases  might  or  might  not  receive  the  necessary 
attention,  but  with  the  nurse  all  uncertainty  was  dispelled. 

It  was  also  found  feasible  to  use  the  nurse  during  the  summer 
months  when  there  was  no  school,  in  the  lessening  of  the  great  mortality 
rate  among  infants  from  summer  diarrhea,  due  mainly  to  improper 
care  and  feeding.  Again,  she  aided  materially  in  the  campaign  to  lessen 
the  number  of  cases  and  spread  of  consumption. 

The  following  is  a  report  of  the  work  of  the  trained  nurse  in  the 
schools  of  the  Fourth  Section: 


WORK   OF  THE  TRAINED  NURSE   IN  THE    SCHOOLS    OF 
THE  FOURTH  SECTION,  PHILADELPHIA 

From  Sept.,  1905,  to  June,  1906 

Schools  visited 5 

Scholars  in  attendance 4800 

Visits  to  schools 656 

Old  cases  treated 3863 

New  cases  treated 907 

Total  number  of  cases 477° 

Cases  cured 781 

Taken  to  dispensaries 49 

Visits  to  dispensaries 97 

Cases  treated  at  home 342 

Visits  to  homes 533 


The  School  Nurse  71 


Cases  Treated  at  School 

Pediculosis 249 

Impetigo 98 

Ringworm  of  body 30 

Ringwonn  of  head 6 

Eczema 85 

Conjunctivitis 126 

Stye 4 

Favus 2 

Pustular  dermatitis 15 

Infected  wounds,  contusions,  etc 113 

Miscellaneous 55 

Defective  vision;  glasses  furnished 124 


NURSE'S  VISITS  TO  HOMES 

From  Sept.,  1905  to  June,  1906 

Disease  No.  of  No.  of  No.  Cured 

Cases  Visits 

Defective  vision 138  172  124  procured  glasses 

Scabies 8  25  8 

Favus 2  19  2 

Acute  conjunctivitis 5  30  4 

Discharging  ear 4  7  4 

Not  vaccinated 12  12  12 

Pediculosis 121  143  78 

Pustular  dermatitis 14  25  14 

Uncleanliness 19  27  19 

Congenital  deformity i  3  Admitted     to    Widener 

Memorial  Home 

Ringworm 5  29  5 

Improperly  nourished 13  22  Proper         nourishment 

obtained 

Children  Taken  to  Dispensaries 

Disease  No.  of  No.  of 

Cases  Visits 

Defective  vision 41  63 

Favus 2  7 

Acute  conjunctivitis 3  14 

Scabies 3  13 

In  explanation  of  the  above  report  of  the  trained  nurse,  Dr.  New- 
mayer  submits  the  following: 

"The  percentage  of  pediculosis  existing  in  these  schools 
when  the  nurse  began  work  in  April,  1904,  was  thirty 


72  Medical  Inspection  of  Schools 

per  cent.  This  has  since  been  reduced  to  eight  per  cent. 
Most  of  these  cases  were  absolute  cures,  as  the  disease 
has  not  recurred  in  the  same  scholars.  This  is  mainly 
due  to  the  influence  at  the  homes  by  the  nurse.  There 
remain  very  few  cases  of  ringworm  and  impetigo,  which 
at  first  were  prevalent  in  large  numbers.  Conjunctivitis 
and  corneal  ulcers  received  no  attention  from  the  parents, 
and  were  treated  only  after  the  children  were  taken  in 
charge  by  the  nurse.  They  were  soon  cured  and  the 
children  able  to  resume  their  studies.  These  cases  in- 
cluded several  in  which  corneal  ulcer  threatened  the 
sight.  Weak,  anemic  children,  unable  to  work  or  study, 
due  to  impoverishment  from  improper  food,  were  visited 
in  their  homes,  and  the  existing  difficulties,  whether  ex- 
treme poverty,  sick  or  drunken  parents,  corrected.  Over 
two  hundred  children  with  bad,  defective  vision  were 
treated  and  supplied  with  necessary  glasses  only  through 
much  persuasion  and  the  most  persistent  efforts  of  the 
nurse.     This  often  required  many  visits  to  the  homes." 

Wherever  they  are  employed,  the  home  visiting  by  the  school  nurses 
is  recognized  as  one  of  the  most  important,  if  not  the  most  important, 
feature  of  the  whole  system.  Dr.  H.  W.  Buckler,  one  of  the  medical 
inspectors  of  Baltimore,  says  that  this  feature  of  the  work  is  the  most 
efficacious  in  its  direct  results  and  the  most  far-reaching  in  its  indirect 
influences.^  In  the  home  the  nurse  has  opportunities  of  detecting  and 
correcting  the  causes  that  produce  the  trouble  for  which  treatment 
was  advised.  Often  entire  families  are  foimd  to  be  suffering  from  the 
same  disease  for  which  the  child  was  excluded,  showing  how  utterly 
useless  the  work  in  the  school  would  be  in  such  cases  without  the  nurse 
to  attack  the  root  of  the  evil  in  the  home.  The  nurse  on  her  first  visit 
explains  why  the  child  has  been  excluded  and  what  has  to  be  done, 
often  giving  a  practical  demonstration  of  the  treatment  needed.  If 
the  condition  is  one  which  calls  for  a  physician's  services,  she  urges 
upon  the  family  the  necessity  of  calling  their  regular  doctor  or,  in  the 
case  of  very  poor  families,  she  often  takes  the  child  to  the  proper  dis- 
pensary and  sees  that  it  gets  the  treatment  required.     The  nurse's 


The  School  Nurse  73 

opportunities  for  advising  the  family  are  manifold,  as  are  also  her  chances 
of  noting  unsanitary  conditions  and  non-observance  of  the  law  and 
reporting  the  same  to  the  proper  authorities. 

In  Boston  the  nurses  are  under  the  Department  of  School  Hygiene, 
which  is  an  integral  branch  of  the  educational  system. 

The  nursing  division  of  the  department  is  under  the  direction  of 
one  supervising  nurse  who  has  at  present  thirty-four  assistants.  The 
division  is  provided  for  by  an  additional  special  appropriation  of  $25,000 
annually.  Rooms  are  equipped  at  schools  in  each  district,  and  each 
nurse  has  an  assignment  of  approximately  2,700  pupils.  These  nurses 
are  appointed  from  a  certified  list  similar  to  that  of  other  employees 
in  the  service.  The  following  report  of  the  work  of  the  first  twenty  nurses 
appointed  imder  this  department  for  the  period  September  11,  1907,  to 
February  i,  1908,  shows  what  is  possible  under  this  adjunct  to  health 
and  efiiciency. 

Diseases  of:  Ear,  1,492  cases  cared  for;  Eye,  6,078  cases  cared 
for,  including  3,649  suffering  from  defective  vision;  of  these  1,131  were 
corrected  by  oculists ;  Nose,  2,602  cases,  of  which  1,405  had  adenoids, 
423  of  whom  had  the  obstruction  removed;  Mouth,  1,765  cases,  includ- 
ing 1,686  who  had  carious  teeth;  Throat,  1,695  cases,  including  683 
of  hypertrophied  tonsils,  and  608  of  tonsillitis;  Skin,  10,139  cases,  all 
of  which  were  followed  to  their  homes  and  the  parent  or  guardian 
instructed  how  to  care  for  the  same. 

In  addition  to  the  above,  2,563  pupils  having  abrasions  and  wounds 
received  9,144  dressings;  2,034  miscellaneous  affections,  including 
350  septic  wounds,  312  suffering  from  renal  disease,  121  having  rachitis, 
207  suffering  from  malnutrition,  227  with  epilepsy,  126  with  chorea, 
and  548  with  bronchitis,  anasmia,  and  heart  disease,  were  treated; 
3,293  were  taken  to  family  physicians,  resulting  in  3,202  being  cured 
and  retm^ned  to  school  at  the  minimum  of  absenteeism;  4,773  were 
taken  to  hospitals  on  request  of  parents;  and  3,223  of  these  were  cured 
and  returned  to  school;  7,559  home  visits  were  made  for  the  purpose 
of  instructing  or  advising  parents  concerning  the  children,  or  in  order 
to  persuade  the  parents  to  seek  proper  medical  or  surgical  aid  for  the 
child.  There  were  also  2,882  affections  looked  after,  of  which  there  is 
no  classification.     These  do  not  include  the  specific  infectious  diseases. 

In  New  York  City  the  following  account  of  the  duties  of  the  school 


74  Medical  Inspection  of  Schools 

nurses  was  given  in  a  pamphlet  published  by  the  Department  of  Health 

in  1906: 

Duties  of  Supervising  Nurse 
The  supervising  nurse  has  entire  charge  of  all  of  the 
nurses.  She  assigns  the  nurses  to  duty  at  certain  schools, 
sees  that  necessary  supplies  are  furnished,  instructs  the 
nurses  in  their  duties,  inspects  their  work,  receives  their 
reports  of  work  performed  and  keeps  a  record  of  all 
examinations,  treatments  and  diseases  treated  by  each 
nurse  in  each  school. 

Duties  of  School  Nurses 
Each  nurse  is  assigned  a  group  of  schools.     She  reports 
each  day  at  each  school,  at  a  certain  specified  time. 

I .  Morning  Inspection. 

In  a  special  room,  assigned  for  the  piu-pose,  the  nurse 
receives  all  children  ordered  to  report  to  her  for  treatment. 
These  cases  include  pediculosis,  ringworm,  scabies,  favus, 
impetigo,  molluscum  contagiosum  and  conjunctivitis. 
The  treatment  used  for  these  conditions  is  as  follows: 

Pediculosis:  Children  are  assembled  in  groups  and 
are  instructed  orally,  and  by  means  of  circulars  printed 
in  a  language  suited  to  the  nationality  of  the  child,  as  to 
the  methods  of  home  treatment.  These  cases  are  not 
treated  in  school. 

Cases  to  be  Visited  by  the  Nurse  at  the  Home  of 
THE  Children 

1.  Flagrant  cases  of  pediculosis.  The  nurse  shows 
the  mother  how  to  treat  the  condition  and  encourages 
persistence. 

2.  Excluded  cases  who  do  not  return  at  the  appointed 
time. 

3.  Trachoma  cases  where  treatment  is  not  sought 
regularly.  The  nurse  urges  the  need  of  treatment,  and 
if  necessary  takes  the  child  to  a  dispensary. 


The  School  Nurse  75 

The  nurse  is  not  allowed  to  treat  cases  of  trachoma. 
Children  so  affected  must  report  to  the  nurse  each  week 
and  show  a  physician's  certificate  card,  properly  dated, 
showing  evidence  that  the  child  is  continuously  under 
treatment.  Persistent  failure  to  show  such  evidence  is 
cause  for  exclusion. 

2.  Routine  Inspection. 

When  morning  inspection  has  been  completed,  the 
niirse  visits  the  classrooms  and  makes  a  weekly  routine 
inspection  of  the  eyelids,  hair,  skin,  and  throat  of  each 
pupil. 

The  nurses  keep  a  special  set  of  index  cards.  All 
cases  of  contagious  disease  found  are  noted  on  these 
cards.  Special  cards  are  kept  for  recording  all  cases 
of  pediculosis ;  these  cases  are  under  the  exclusive  care  of 
the  nurse.  Other  cases  are  noted  and  ordered  to  report 
to  the  medical  inspector  for  the  purpose  of  confirming  the 
diagnosis.  The  nurse  must  exclude  all  children  showing 
symptoms  of  diphtheria,  scarlet  fever,  measles,  whooping 
cough,  chicken-pox,  or  mumps,  and  if  the  inspector  is  not 
in  the  school  to  confirm  the  diagnosis,  telephone  the  name 
and  address  of  each  excluded  child  to  the  central  office. 
An  inspector  is  then  sent  to  the  home  of  the  child  and 
takes  further  charge  of  the  case. 

The  nurse  forwards  each  day  to  the  supervising  nurse 
a  record  of  the  work  performed  that  day,  including: 

Number  of  children  examined 

Number  of  children  excluded 

Number  of  children  treated 

Number  and  character  of  diseases  treated 

Number  of  visits  made  to  children  at  their  homes 

The  nurse  also  sends  to  the  supervising  nurse,  each 
week,  a  report  giving  the  total  amoimt  and  character  of  the 
work  performed  during  the  week. 


76  Medical  Inspection  of  Schools 

Dr.  Cornell  gives  the  following  account  of  the  duties  of  the  school 
nurse  in  Philadelphia: 

"Five  nurses  are  maintained  by  the  city  for  work  in 
the  congested  quarters.  Their  duties  consist  in  curing  the 
numerous  minor  skin  diseases  existing  coincidently  with 
poor  nutrition  and  unhygienic  surroundings,  looking 
after  other  minor  cuts,  sprains,  etc.,  occasionally  examin- 
ing children  for  pediculosis,  when  several  cases  have 
occurred  in  a  class,  and  in  visiting  the  parents  of  children 
suffering  from  physical  defects,  for  the  purpose  of  urging 
treatment.  Occasional  visits  are  made  to  dispensaries 
with  the  children.  The  efficiency  of  these  nurses  depends 
largely  upon  their  personality.  As  a  rule,  in  foreign 
poverty-stricken  sections,  they  are  invaluable.  It  does 
not  appear  that  their  sphere  would  extend  beyond  the 
home  visiting  for  the  purpose  of  urging  treatment,  in  the 
other  sections  of  the  city. 

"In  those  schools  visited  by  both  the  medical  inspector 
and  the  nurse,  the  nurse  is  subordinate  to  the  medical  in- 
spector. The  method  of  action  and  record  in  these  schools 
is  for  the  medical  inspector  to  leave  the  small  blue  cards, 
each  containing  the  record  of  some  child's  physical  defect, 
for  the  nurse's  enlightenment.  The  nurse  sends  for  the 
children  by  means  of  these  cards,  and  either  treats  them 
at  the  time  or  makes  a  note  of  home  visits  required. 
When  the  case  is  disposed  of,  she  makes  such  disposition: 
'eye-glasses,  Pennsylvania  Hospital';  'sent  to  Dr. 
Schamberg,'  skin  specialist;  'glasses.  City  Hall' — meaning 
a  case  for  free  treatment  and  glasses  by  the  city  ophthal- 
mologist, and  returns  these  cards  to  the  medical  inspector, 
who  finally  files  them  at  the  central  office." 


The  School  Nurse  77 

FORMS  USED  IN  CONNECTION  WITH  WORK 
OF  NURSES 

In  the  report  of  the  work  in  Philadelphia  quoted  above,  Dr.  Cornell 
mentions  the  small  blue  cards  made  out  by  the  medical  inspectors 
which  contain  the  record  of  some  child's  physical  defect  and  are  left 
for  the  nurse's  enlightenment.  The  following  is  a  reproduction  of  the 
card  referred  to: 


CARD   RECOMMENDING  PUPIL  FOR  TREATMENT. 
PHILADELPHIA 

RECOMMENDED  FOR  TREATMENT 


School .^ __^  Section^ 

Name 


Address 


Cause. 


Date  of  Recommendation. 

I  Physician 
Referred  to-<  Dispensary 
(Hospital 


Result . 


.Medical  Inspector 


Every  nurse  sends  each  week  a  report  to  the  chief  medical  inspector 
of  what  she  has  done  during  the  week.  The  following  is  a  reproduction 
of  the  form  used: 


78  Medical  Inspection  of  Schools 

WEEKLY  REPORT  OF  NURSE.     PHILADELPHIA 

A.  A.  Cairns,  M.  D., 

Chief  Medical  Inspector. 
Dear  Sir: — 

The  following  is  a  weekly  report  of  Nurse  of  Schools  of 
Fourth  Section. 


Week  Ending. 

1 
> 
1 

J3 
u 

u 

0 

u 

OJ 

2; 

■6 
u 

Diseases  for  which  Pupils  are  Treated. 

Q 

8 

i 
0 

> 

Taken  to  Dispens- 
ary. 

.2 

J 
3 

a 

_3 

"a 

< 

t/2 

0 

c 

5 

1 

g 

1 

fa 

1 

•3 
e 

Q 
3 

•T3 

a 
3 
0 

"a 

1" 

- 

- 

- 

- 

- 

1 

a 

1 

Old 

New 

Old 

New 

T 

C 

Monday  .. 
Tuesday  . . 
Wednesday 
Thursday  . 

Friday 

Saturday . . 

Totals 

Total  numb 

er 

of 

c 

as 

2S 

cure 

d.. 



CASES  TREATED  AT  HOMES 

Date. 

Name. 

Address. 

Disease. 

CASES  TAKEN  TO  DISPENSARY 

Date. 

Name. 

Disease. 

Date. 


Nurse. 


The  School  Nurse  79 

A  simpler  form  of  weekly  report  on  the  nurse's  work  is  in  use  in 
Baltimore. 

WEEKLY  REPORT  OF  NURSE.  BALTIMORE 

SCHOOL  INSPECTION. 

NURSES'  WEEKLY  REPORT. 


No.  of  pupils  inspected  in  school 

(Work  with  School  Inspector  not  included) 

No.  of  pupils  inspected  at  home 

No.  of  pupils  treated  in  school 

No.  of  pupils  treated  at  home 

Schools  Visited  Nos 

No.  of  Homes  Visited 

DISEASES  TREATED  IN  SCHOOLS: 


DISEASES  TREATED  IN  HOMES: 


REVERSE  OF  BALTIMORE  CARD 

Difficulties,  if  any,  at  homes : 

Difficulties,  if  any,  in  schools: 

Remarks  : 

Date, 

Nurse. 


8o  Medical  Inspection  of  Schools 

To  sum  up  the  case  for  the  school  nurse — she  is  the  teacher  of  the 
parents,  the  pupils,  the  teachers,  and  the  family  in  applied  practical 
hygiene.  Her  work  prevents  loss  of  time  on  the  part  of  the  pupils 
and  vastly  reduces  the  number  of  exclusions  for  contagious  diseases. 
She  cures  minor  ailments  in  the  school  and  furnishes  efficient  aid  in 
emergencies.  She  gives  practical  demonstrations  in  the  home  of 
required  treatments,  often  discovering  there  the  source  of  the  trouble, 
which  if  undiscovered,  would  render  useless  the  work  of  the  medical 
inspector  in  the  school.  The  school  nvu-se  is  the  most  efficient  possible 
link  between  the  school  and  the  home.  Her  work  is  immensely  im- 
portant in  its  direct  results  and  very  far-reaching  in  its  indirect  in- 
fluences. Among  foreign  populations  she  is  a  very  potent  force  for 
Americanization. 


CHAPTER  VII 

Physical  Examinations  for  the  Detection 
of  Non-Contagious  Defects 

The  whole  theory  on  which  physical  examinations  conducted  for 
the  detection  of  defects  are  based  rests  on  a  different  foundation  from 
that  vmderlying  medical  inspection  for  contagious  diseases.  The  latter 
is  primarily  a  protective  measure  and  looks  mainly  to  the  present 
safeguarding  of  the  community.  The  former  aims  at  securing  physical 
soundness  and  strength,  and  looks  far  into  the  future. 

It  has  been  brought  into  being  by  the  great  mass  of  evidence  showing 
conclusively  that  a  very  large  percentage  of  school  children — probably 
from  a  quarter  to  a  third  of  all  of  them — are  defective  in  vision  to  the 
extent  of  requiring  an  oculist's  care  if  they  are  to  do  their  work  properly 
and  if  permanent  injury  to  their  eyes  is  to  be  prevented.  These  con- 
clusions are  based  upon  examinations  of  hundreds  of  thousands  of 
children  in  all  parts  of  the  world.  There  is  no  doubt  as  to  the  sub- 
stantial accuracy  of  the  results.  More  than  this,  a  considerable  per 
cent. — probably  about  five — of  school  children  are  so  seriously  defective 
in  hearing  that  their  school  work  is  badly  interfered  with.  Most  im- 
portant of  all,  only  a  small  minority  of  these  dejects  of  sight  and  hearing 
are  discovered  by  teachers  or  are  knoivn  to  them,  to  the  parents,  or  to  the 
children  themselves.  When  children  attempt  to  do  their  school  work 
while  suffering  from  these  defects,  among  the  results  may  be  counted 
great  injury  to  the  eyes,  sometimes  resulting  in  blindness,  permanent 
injur)'  to  the  nervous  system  owing  to  eye  straining,  and  depression  and 
discouragement  owing  to  inability  to  hear  and  see  clearly. 

But  not  only  are  eyesight  and  hearing  important,  there  are  many 
other  defects  far  from  rare  among  children  and  having  an  important 
bearing  on  their  present  health  and  future  development  which,  if  dis- 
covered early  enough,  may  easily  be  remedied  or  modified. 
6  8i 


82  Medical  Inspection  of  Schools 

The  argument  for  the  physical  examination  of  school  children  is 
based  on  a  recognition  of  the  important  bearing  of  the  physical  and 
mental  condition  of  the  children  on  the  whole  process  of  education. 
It  recognizes  the  necessity  of  a  favorable  physical  and  educational 
environment,  and  by  emphasizing  the  importance  of  the  effect  of  sur- 
roundings upon  the  personality  of  the  individual  child  seeks  to  secure 
for  each  pupil  such  conditions  of  life  as  will  secure  a  full  and  effective 
development  of  its  bodily  strength  and  mental  power. 

In  America  comprehensive  systems  embracing  thorough  medical 
examinations  of  all  pupils  are  still  rare.  The  oldest  such  system  in 
public  schools  is  of  comparatively  recent  origin.  Partial  examinations, 
however,  have  been  made  in  many  places  and  tests  of  eyesight  and  hear- 
ing are  by  no  means  rare.  In  the  nature  of  the  case  there  has  been  so 
great  variation  in  the  methods  used  in  conducting  these  tests  that  the 
results  found  in  different  cities,  where  examinations  have  been  conducted 
perhaps  under  radically  different  conditions,  are  not  directly  comparable 
with  each  other.  Nevertheless  an  examination  of  the  available  data 
serves  to  emphasize  the  far-reaching  importance  of  doing  something 
to  better  existing  conditions  and  to  show  that  eyesight  and  hearing 
troubles  are  not  confined  to  any  one  locality  or  to  large  cities  only. 
In  the  table  on  page  83  are  shown  the  results  of  different  recently 
conducted  eyesight  and  hearing  tests. 

In  examining  this  table  one  is  at  once  struck  by  the  variations  between 
the  figures  in  the  column  giving  the  percentages  of  defective  vision 
for  the  several  places.  Thus,  Bayonne  reports  only  7.7  per  cent, 
defective,  while  the  congested  districts  of  Cleveland  report  71.7  per 
cent.  Of  course,  such  variations  as  this  at  once  suggest  what  is  un- 
doubtedly the  case,  that  the  results  are  largely  influenced  by  the  methods 
employed  by  the  examiners,  and  variations  from  this  cause  are  apt  to 
be  even  more  important  than  those  caused  by  the  actual  differences 
in  existing  conditions.  Leaving  out  of  account  such  extreme  cases 
as  those  cited,  it  will  be  noticed  that  in  a  considerable  part  of  the  cases 
the  children  having  defective  vision  are  from  20  to  30  per  cent,  of  the 
whole  number  examined. 

In  the  two  examinations  conducted  in  Cleveland  in  1907,  the  per- 
centage of  those  having  defective  eyesight  in  the  well-to-do  district 
was  32.4,  while  in  about  the  same  number  of  cases  in  a  congested  dis- 


Physical  Examinations  for  Non-Contagious  Defects    83 

trict  it  was  71.7.  It  is  said  that  every  endeavor  was  made  to  use  just 
the  same  standards  in  the  examinations  in  these  two  tests.  Certainly 
this  is  interesting,  and  suggests  the  importance  of  conducting  similar 
tests  in  other  cities. 


RESULTS   OF   VISION  AND  HEARING  TESTS  CONDUCTED 
IN  PUBLIC  SCHOOLS 

p  Datf         Number     DEFEcrm:      Per       Defective    Per 

'^^^■'^-  UATE.        ExAiQNED.        ViSION.  CeNT.         HEARING.     CeXT. 

Bayonne,  N.  J 4,610  353  7.7  115         2.5 

Camden,  N.  J 1906  10,028  2,757  27.7  412         4.1 

Cleveland 1900  30,045  6,221  20.7  .... 

Cleveland,    well-to-do      dis- 
trict   1907  668  216  32.4  34        5.2 

Cleveland,    congested       dis- 
trict   1907  616  437  71.7  II         1.8 

Dunfermline 1907  1,526  255  17.0          4.0 

Edinburgh 1904  ^,33°  574  43-2  162       12.2 

Massachusetts 1907  402,937  99,609  22.3  27,387         6.3 

Counties    of    Mass.    except 

Suffolk 1907            19.9          5.8 

Suffolk      Coxrnty      (Boston, 
Chelsea,      Revere,      Win- 

throp) 1907  30.7           7.7 

Milwaukee 1907  1,960  293  14.9          

Minneapolis 25,696  8,166  30.0          

Minneapolis 1908  710  170  23.9  55         7.7 

New  York  City 1906  79.065  24,534  31.3  1,633         2.0 

Pawtucket,  R.  1 1901  4,663  517  11. i  200         4.3 

Utica,  N.  Y 1897  6,113  667  10.9  406        6.6 

Worcester,  Mass ii)953  2,281  19. i  313         6.6 

Another  point  which  may  be  of  significance  is  that  in  the  state  ex- 
aminations of  Massachusetts  the  percentage  of  defective  vision  of  the 
counties  of  the  state  outside  of  Suffolk  County  was  19.9,  while  Suffolk 
County,  which  is  almost  entirely  the  city  of  Boston,  reports  30.7  per 
cent.  In  corroboration  of  the  suggestion  that  defective  vision  is  more 
prevalent  in  cities  than  in  country  districts  are  also  the  figures  from 
Scotland,  where  the  city  of  Edinburgh  reports  43.2  per  cent,  defective, 
while  the  town  of  Dunfermline  reports  only  17.0. 

It  is  to  be  noted  that  a  similar  situation  exists  with  regard  to  the 


INDIVIDUAL  RECORD  CARD,  NEW  YORK  CITY 


H 


•C    OQ 


*'   Q 


^.    i 


M 

lb 

' 

« 

CD 

N 

s 

- 

n 

(0 

- 

M 

10 

- 

^ 

N 

*■ 

N 

o 

- 

N 

(M 

- 

M 

- 

K 

A 

IV> 

a 

I 

b! 

o 

a 

1 

3 

i 

5 

1 

1 

a. 

o 

1 

A 

M 

^ 

1 

3 

=3 

4 

•a 
1 

1 

a 

3 

5 
1 

o 

■5 

1 
1 
1 

■a 

a 

i 

1 

1 

§ 

1 

1 

■E 
1 
o 

1 

1 

o 

1 

1 

O 

1 

1 

1 

a 

1 

1 

a 

•a 
1 

1 

f 

a 
o 
1 

1 

^ 

eJ 

fj 

■^ 

19 

c 

GO 

o 

s 

rs 

•^ 

n 

« 

1^ 

ai 

a 

o 

J 

ei 

w 

•* 

ift 

o 

►■ 

QO 

It 

" 

"^ 

i-i 

d 

N 

e< 

N 

ei 

M 

M 

*» 

84 


Physical  Examinations  for  Non-Contagious  Defects   85 

figures  for  hearing  from  these  same  locahties.  The  counties  of  Mass- 
achusetts outside  of  Suffolk  report  5.8  per  cent,  defective  in  hearing 
while  Suft'olk  reports  7.7  per  cent.  Dunfermline  reports  4  per  cent., 
as  contrasted  with  12.2  per  cent,  from  Edinburgh. 

In  general,  from  5  to  6  per  cent,  of  children  examined  are  foimd  to 
have  defective  hearing. 

Turning  our  attention  now  from  tests  for  vision  and  hearing  to  more 
comprehensive  physical  examinations,  we  are  at  once  attracted  to  the 
situation  in  New  York.  Up  to  the  spring  of  1903  the  whole  attention 
of  the  medical  inspectors  in  New  York  had  been  directed  against  in- 
fectious and  contagious  diseases.  In  March  of  that  year  the  system 
was  so  elaborated  as  to  continue  with  the  former  work  and  at  the  same 
time  to  include  the  complete  physical  examination  of  each  child. 

Since  that  time  there  has  been  but  little  change  in  the  list  of  defects 
examined  for.  Immediately  after  the  morning  inspection  for  conta- 
gious diseases  has  been  concluded  the  inspector  receives  the  children 
of  a  class  in  turn  in  a  special  room  set  aside  for  the  purpose  and  examines 
them  for  sight,  hearing  and  physical  defects.  The  headings  under 
which  entries  are  made  can  be  seen  by  referring  to  the  reproduction  of 
the  individual  record  card  in  use  in  the  New  York  schools. 

In  every  case  where  a  defective  condition  is  found  to  exist  the  parent 
of  the  child  is  notified  by  means  of  a  printed  postal  card  form.  The 
postal  cards  used  are  of  the  "reply"  form.  The  postal  card  informing 
the  parent  that  his  child  has  some  physical  defect  has  on  it  the  direc- 
tions: "  Take  the  child  to  your  family  physician  for  treatment  and  advice. 
Take  this  card  with  you  to  your  family  physician."  Attached  to  this 
card  is  another  which  the  family  physician  to  whom  the  case  is  referred 
is  asked  to  fill  in,  telling  what  action  he  has  taken,  and  mail  to  the  chief 
medical  inspector.  This  system  allows  of  following  up  the  cases. 
If  the  reply  card  is  received,  the  authorities  know  that  action  has  been 
taken  in  regard  to  the  case.  If  no  reply  is  received,  the  case  demands 
further  attention. 

The  results  of  the  New  York  examinations  have  attracted  wide- 
spread attention,  and  a  large  number  of  newspaper  and  magazine  articles 
have  been  written  about  this  work  in  New  York.  There  has  been 
much  discussion  as  to  whether  the  conditions  found  by  the  doctors  in 
New  York  were  t}^ical  of  conditions  existing  in  other  cities  or  were 


86  Medical  Inspection  of  Schools 

POSTAL  CARD  NOTICE  TO  PARENTS,  NEW  YORK 

"  This  Notice  Does  NOT  Exclude  This  Child  From  School " 

DEPARTMENT  OF  HEALTH 
THE  CITY  OF  NEW  YORK 

190 

The  parent  or  guardian  of 

of attending  P.  S 

is  hereby  informed  that  a  physical  examination  of  this  child  seems  to 
show  an  abnormal  condition  of  the 

Remarks 

Take  this  child  to  your  family  physician  for  treatment  and  advice. 
Take  this  card  with  you  to  the  family  physician, 

THOMAS  DARLINGTON,  M.  D., 

Commissioner  of  Health. 
HERMANN  M.  BIGGS,  M.  D., 

General  Medical  Officer. 


REVERSE  OF  CARD 
TAKE  THIS  CARD  TO  YOUR  PHYSICIAN 

The  Physician  in  charge  is  requested  to  fill  out  and  forward  this 
postal  after  he  has  examined  this  child. 

I  have  this  day  examined 

of  P.  S and  find  the  following  condition: 


and  advised  as  follows: 

Respectfully  yours. 

Date 


Physical  Examinations  for  Non-Cont'agious  Defects  87 

exceptional.  Unfortunately  not  enough  work  of  a  similar  natxire  has 
been  done  in  other  places  to  furnish  data  for  answering  these  questions, 
and  where  the  work  has  been  done  the  results  are  not  usually  in  such 
statistical  form  as  to  allow  of  comparison.  Almost  the  only  available 
figures  are  from  Minneapolis  and  are  for  a  small  number  of  cases. 
Nevertheless  it  is  interesting  to  compare  these  figures  with  those  for 
New  York  for  the  year  1906. 


1908. 

Per  Cent. 

710 

100.0 

166 

23-3 

377 

53-0 

2 

0.3 

15 

2.1 

30 

4.2 

12 

1.6 

PHYSICAL   EXAMINATIONS   IN   NEW   YORK   AND 
MINNEAPOLIS 

New  York  City, 

1906.  Per  Cent. 

Number  examined 78,401  loo.o 

Bad  nutrition 4)92i  6.3 

Anterior  cervical  glands 29,1 77  37.2 

Posterior  cervical  glands 8,664  n-o 

Chorea 1,380  1.7 

Cardiac  disease 1,096  1.4 

Pulmonary  disease 757  .9 

Skin  disease i)558  i-9 

Deformity  of  spine 424  .5 

Deformity  of  chest 261  .3 

Deformity  of  extremities 550  .7 

Defective  vision 17,928  22.8 

Defective  hearing 86g  i.i 

Defective  nasal  breathing 11,314  i4-4 

Defective  teeth 39;597  SS-o 

Defective  palate 831  i.o 

Hypertrophied  tonsils 18,306  23.3 

Postnasal  growth 9,438  12.0 

Defective  mentality i)857  2-3                 ••- 

Where  treatment  was  necessary...  56,259  71.7                462 


170 

23-9 

55 

7-7 

309 

43-5 

2 

0.2 

221 

3I-I 

91 

12.8 

65.1 


On  the  whole  the  figures  in  the  per  cent,  columns  show  substantial 
agreement.  It  is  to  be  supposed  that  the  great  difference  under  the 
heading  "  Bad  nutrition"  (6.3  per  cent,  in  New  York  and  23.3  in  Minne- 
apolis) is  due  to  a  different  standard  rather  than  to  any  great  difference 
in  conditions.  Under  "Defective  hearing,"  again,  there  is  a  striking 
difference,  the  New  York  figure  being  i.i,  while  that  of  Minneapolis 
is  7.7.     As  so  low  a  percentage  as  that  given  for  New  York  is  very 


88  Medical  Inspection  of  Schools 

rarely  found  elsewhere,  here  again  it  must  be  concluded  that  the 
standard  in  New  York  must  be  less  rigid  than  in  other  places. 

Perhaps  the  most  interesting  figures  of  all  are  those  for  "WTiere 
treatment  was  necessary."  The  percentages  are  71.7  for  New  York 
and  65.1  for  Minneapolis. 

This  is  a  feature  of  interpreting  the  results  of  the  work  of  physical 
examinations  which  has  caused  many  misapprehensions.  It  has  been 
stated  again  and  again  that  the  results  of  physical  examinations  in 
New  York  proved  that  two-thirds  of  all  the  school  children  were  defec- 
tive, and  such  statements  have  aroused  much  discussion  and  called  forth 
some  denials.  The  trouble  is  one  of  words  rather  than  facts.  To 
use  the  word  "defective"  as  it  has  been  used  in  this  way  is  to  give  it  a 
new  meaning.  WTiat  the  figures  really  show  is  that  more  than  two- 
thirds  of  the  children  are  found  to  have  defects  serious  enough  to  record 
them  and  which  call  for  attention  from  a  physician,  surgeon  or  dentist. 
Nevertheless  the  defects  so  recorded  may  be  nothing  more  serious  than 
a  carious  tooth. 

Judgment  as  to  what  constitutes  a  defect  serious  enough  to  warrant 
including  the  child  in  the  class  "defective"  varies  greatly  in  different 
places.  Recently  newspaper  articles  announced  that  examinations  of 
school  children  in  Sioux  City  showed  that  80  per  cent,  were  defective, 
w^hile  a  little  later  they  announced  that  only  18  per  cent,  were  defective 
in  Minneapolis.  This  latter  figure  represented  the  proportion  the  physi- 
cians in  the  latter  city  considered  "seriously  defective."  Of  course, 
it  must  be  remembered  in  this  connection  that  the  perfect  human 
animal  is  exceedingly  rare.  At  a  recent  examination  in  Chicopee, 
Mass.,  out  of  500  pupils  examined  only  one  was  reported  as  having 
perfect  teeth,  and  this  one  was  found  to  have  spinal  trouble,  so  that  not  a 
single  pupil  was  reported  as  being  perfectly  sound  physically. 

All  this  does  not  mean,  how^ever,  that  our  schools  are  filled  with 
physical  wrecks.  WTiile  the  results  of  the  examinations  prove  beyond 
doubt  the  need  for  finding  out  the  facts  and  taking  steps  to  have  defects 
remedied,  the  need  for  moderation  of  statement  in  making  public  the 
results  is  no  less  apparent. 

In  any  system  of  medical  inspection  which  includes  the  feature 
of  physical  examinations  the  matter  of  keeping  records  is  of  the  greatest 
importance.     To  begin  with,  a  good  system  of  individual  records  is 


Physical  Examinations  for  Non-Contagious  Defects   89 

imperative.  This  is  a  field  of  work  where  general  information  will 
not  do.  There  must  be  a  complete  individual  record  for  each  child. 
This  record  card  or  blank  must  have  on  it  spaces  for  recording  the 
results  of  subsequent  examinations  as  well  as  the  initial  one.  If  the 
results  of  the  work  are  to  be  of  real  practical  value,  there  must  be  the 
closest  connection  bet^veen  the  records  of  the  physical  examinations 
and  the  classroom  work.  It  does  no  good  to  have  a  record  on  a  card 
in  the  principal's  room  or  in  the  office  of  the  board  of  health  to  the 
effect  that  Willie  is  stone  deaf  in  the  right  ear,  if  the  teacher  knows 
nothing  of  the  fact  and  still  has  Willie  seated  in  the  back  left-hand 
comer  of  the  room.  It  is  also  obvious  that  if  the  records  do  not  follow 
the  child  from  room  to  room,  and  school  to  school,  in  case  of  transfers, 
much  of  the  work  is  soon  rendered  useless. 

These  are  some  of  the  reasons  why  a  system  of  medical  inspection 
with  physical  examinations  is  an  entirely  different  problem,  from  the 
point  of  view  of  the  school  administration,  from  a  system  for  the  detec- 
tion of  contagious  diseases  only. 

Experience  proves  that  the  latter  sort  of  work  can  be  handled  satis- 
factorily by  boards  of  health.  In  the  system  having  physical  examina- 
tions as  an  important  featiire  the  educational  authorities  must  in  any 
event  have  an  active  participation  in  the  work,  and  will  probably  succeed 
much  better  if  they  have  it  entirely  in  their  own  hands. 

The  necessity  for  applying  the  information  gained  through  the  work 
of  the  school  physician  to  the  work  of  the  classroom  has  been  recog- 
nized in  Los  Angeles  and  some  other  cities  by  having  the  teacher's  roll 
books  so  made  that  in  case  any  child  has  a  physical  defect,  the  fact  is 
entered  in  a  space  beside  his  name  in  the  book. 

Pasadena,  California,  recognizes  the  importance  that  the  teacher's 
intimate  knowledge  of  the  child  and  his  habits  has  for  the  school  physi- 
cian who  is  conducting  physical  examinations.  In  that  city  individual 
cards  are  used  for  recording  the  results  of  the  physical  examinations 
made  by  the  school  doctors,  and  on  the  reverse  of  the  cards  are  blanks 
which  the  teacher  fills  in,  indicating  the  points  which  her  knowledge 
of  the  child  leads  her  to  believe  require  attention.  Of  course,  the  teacher 
fills  in  her  side  of  the  card  first,  and  the  physician  uses  the  information 
as  a  guide  and  assistance  in  making  the  physical  examinations. 


90  Medical  Inspection  of  Schools 

RECORD  CARD,  SHOWING  TEACHER'S  COMMENTS  ON 

HABITS  AND  PECULIARITIES  OF  PUPIL. 

PASADENA,  CAL. 

HEALTH  DEPARTMENT,  PASADENA  PUBLIC  SCHOOLS 

Date 

Pupil's  Name 

Parent's  Name  

Address 

1  Posture 

2  Nutrition 


3     Color 


4    Activity,  mental 


5    Activity,  physical 


6     Teeth:  crooked,  prominent,  decayed 


7     Mouth  breather 


8    Frequent  absences 


g     Bad  behavior 


lo    Inattention 


Delinquency  in  studies 


1 2     Squinting,  or  other  eye  symptoms 


13     Deafness 


14    Nasal  voice 


15     Frequent  colds 


1 6    Skin  diseases  or  pimples 


17  Twitching  0}  eyes,  face  or  any  part 

18  Offensive  breath 


19    Over  development,  physical 


20     Under  development,  physical 


21     Uncleanliness 


22     Vicious  personal  habits 


23     Signs  of  fever 


24    Signs  of  any  contagious  disease 


25     Cough 


The  Teacher  will  please  fill  in  the  blanks  at  the  top  of  this  card,  and  check  off  the  points 
which  she  thinks  require  attention. 


Physical  Examinations  for  Non-Contagious  Defects    91 


REVERSE  OF  CARD,  SHOWING  BLANKS  FILLED  IN  BY 
SCHOOL  PHYSICLAJ^ 


PHYSICAL  EXAMINATION 


No. 


Heart 


Lungs 


Eyes 


Ears 


Nose 


Throat 


Teeth 


Contagious  Disease 


Skin  Disease 


Special  Data 


Recommendations 


Results 


Medical  Examiner. 


92 


Medical  Inspection  of  Schools 


< 
o 

CO 

pa 

o 

< 

CO 

O 

(S 
< 

o 
p^ 
o 
o 

>^ 
o 

1-H 

CO 

{>« 
5 


CO 

u 
_] 
u 

O 

o 
>-) 

I 
o 


5 

SI 

a    - 

N 

a  s 
^  o 

a 
O 

a 
> 


< 

B 
H 

< 


P< 


^  _: 
o  -H 
il  P 


o 
o 
Ph 

o 


3 


o 
o 

Ph 


c3 


O 
O 

o 


:3 

w 

(=1 


O 
feb 


"o)   I    feb 


rt 

(U 

^■s 

^ 

hn 

o 

c 

o 

& 

)-( 

^ 

^ 

"Sh. 


•g  o 


.ti  o 


Oj 


Qh5 


rt 


a, 

CO 


<j3 

r-l     !> 


o  i^ 


■  o 

o 


<u    c  -t-> 

as    ^  cQ 

'^  o  ^  .: 

(U  CO  o 


C         '3 


w 


Ph 


T3    O 

^  ? 

(J    c3 

■4-1      O 

^-1  '^ 
[JH    en 

iw 

o 
o 
Ph   >. 


bc  a 

OJ     W     M 


o 


^  ^  ° 
o   I  ^ 


1    3 

>  ^ 


ci    in 


O 
O 

Ph 


.3    biD 

13  .5 


C   rs  ^ 


CO 


i  o   ^i 


CO 
w 

.     l-c 

T3  2  -"^ 
*0  3  "ri 
C  O  .ti 
i^  -^    > 


m 


d     1 

Sh  ^     (L> 

0  ,    =3    - 

1  Oh    I       Ji 

i!2   o-^X 


Ph 


y,   d 


o 

Oh 


P^ 


S  '-' 

O    d 

Oh-1 


•^  s 


<U  -^  .3 
en    1^    '2 

Hi    1^ 


2  Ph    >-! 


>K^-9. 


a, 

d 


<u  ^ 


«  o 

o  ^^ 

^  2.d 

S^I   I 

b  <u  o 

^H  U    <-5 

O  .tH 

'  J2    "^ 


o    u    M  rj^ 


>  1-1 


!1H 


w 


bO 

C 


4)     O 


S 

o 


1^ 

\M'd 

i! 

rt    o 

o 
c  ^ 
o  o 

CO    o 


en  .X 


w 


Physical  Examinations  for  Non-Contagious  Defects    93 


p: 

r/) 

P-. 

0 

•s  s 


Q 

h 

« 

< 

< 

y 

u 

p£4 
0 

< 

X 

M 

hi 

1/2 

« 

J 

^ 

< 

> 

C) 

M 

P:h 

U) 

> 

I 

Q. 

T3 

■^c 

r, 

^^ 

^..iri 

rt 

C 

0 

^"S 

^3 

C3 

frt 

a 

c 

s  0 

§:    0 
Co 

^  > 

en 

CO 

a 
0 

13 

-t-j 

*-<  9 

a  -2 

d 

g 

"5 

0 

0 

« 


Cj 

:=! 

0  jn 

a 

IH 

0 

c 

0 

Ol 

1 

1-1     r£3 

w  3 


D 


<L> 


rn 


T3  13 


g^ 


W 


r    c    i> 

>-c      -^      f^ 

-^^  ^ 

O  t„ 


OJ 


o 


o 

s 

3 


Ph 


n3 

s 


•X3    u 

So 


—    ;h 


S    5J 


O 
P  CO 


J    Ui    <U    S  CO    <U 
r-    s    a    <U    ^    ^  ^ 


rt 


Ph 


-S) 


a 

bO 


2  .ii      rt 


c3 
O    O 


i^  "S  "S  "S  ^"  >^  ^ 

ci.'^  f^  Q  «->  "^  w 
o  ^  ^^£  g^ 

•X3  S   >   g   53 


o 
bO-- 

Vj     O 


c 

Tl 

u 

fl) 

')•"; 

(U 

rt 

C 

a 

0 

rri 

>-i 

« 

^ 

HH 

d 

Pi  <=>\ 

+2  tn  bo 
c3  OJ  <U 
(1)  ■— J    J-i 


o  o 


■g'bb'S 


^    CO    ^    '-' 


O    <"    S^    ^ 


H 


bO 

c 


w 


H 


94 


Medical  Inspection  of  Schools 


A  similar,  but  more  highly  developed,  system  is  in  use  in  the  schools 
of  Los  Angeles,  California.  There  a  standard  five  by  eight  inch  index 
card  is  used  for  the  record  of  each  pupil.  One  side  is  filled  out  by  the 
teacher  and  the  other  by  the  school  physician.  Professor  George  L. 
Leslie,  Director  of  the  Department  of  Health  and  Development  of 
Los  Angeles  City  Schools,  w^rites  as  follows  concerning  the  use  of  this 
card: 

"We  yoke  the  school  teacher  and  the  physician  together 
as  nearly  as  possible  by  the  use  of  the  record  card.  The 
plan  is  not  too  difficult  for  the  teachers  of  the  schools, 
and  very  materially  aids  the  physicians  in  their  v^^ork. 
It  also  emphasizes  the  fact  that  both  teachers  and  parents 
ought  to  and  must  know^  more  of  the  common  develop- 
mental conditions  of  boys  and  girls  as  a  matter  of  every 
day  living,  if  physical  excellence  and  not  degeneracy  is  to 
show  in  the  growth  and  development  of  the  young." 

A  simple  card  for  keeping  the  individual  record  of  physical  examina- 
tions is  in  use  in  Utica,  N.  Y.  It  has  the  shortcoming  of  not  having 
spaces  provided  for  recording  more  than  one  examination. 


PHYSICAL  RECORD  CARD,  UTICA,  N.  Y. 

CITY  OF  UTICA— DEPARTMENT  OF  PUBLIC  SAFETY 

BUREAU  OF  HEALTH 
DIVISION  OF  SCHOOL  INSPECTION 


PHYSICAL  RECORD 

School 

Clnsf; 

Date 

Name 

Age 

A  ddress 

I  Nutr. 

G.  B. 

{  Spine    Y.  N. 

II  Teeth                   G.  B. 

2  Enl.  Cerv.  Gl. 

/Y.N. 
\A.   P. 

7  Defective  \  Chest   Y.  N. 
[  Extrem.Y.N. 

12  Deform.  Palat.    Y.  N. 

13  Hyper.  Tons.       Y.  N. 

3  Chorea 

Y.N. 

SDef.Vis.       {^"^J-Y^S: 

14  P.  Nas.  Growths  Y.  N. 

4  Card.  Dis. 

Y.N. 

15  Mentality             G.  B. 

5  Pulm.  Dis. 

Y.N. 

9  Def.  Hear.              Y.  N. 

16  Treatment 

6  Skin  Dis. 

Y.N. 

10  Def.  Nas.  Breath.  Y.  N. 

necessary  Y.  N. 
17  Nationality 

T^p/m.arks 

Medical  Inspector. 

Physical  Examinations  for  Non-Contagious  Defects  95 

On  this  card  the  letter  G  stands  for  "good,"  B  for  "bad,"  Y  for 
"yes,"  N  for  "no,"  A  for  "anterior,"  P  for  "posterior."  In  filling 
the  card  out  the  letters  are  crossed  out  as  required. 

The  ph3'sical  record  card  now  in  use  in  the  New  York  schools 
(see  page  84)  has  spaces  provided  for  records  of  annual  examinations 
for  nine  years.  A  card  having  spaces  for  five  examinations  is  in  use 
in  Asbury  Park,  N.  J. 


PHYSICAL  RECORD  CARD,  ASBURY  PARK,  N.  J. 
ASBURY  PARK  PUBLIC  SCHOOLS 

DEPARTMENT   OF    MEDICAL    INSPECTION 


No.                               Date 

Class 

Name 

Age 

19 

19 

19 

19 

19 

Weight 

Height 

Inspiration 

Expiration 

rvr-  <"■ 

Naso-Pharynx 

(L. 

Nasal  Septum 

Oen'l 

Teeth 

19 

19 

19 

19 

19 

Heart 

Lungs 

Throat 

Color  Sense 

I  R. 

/l. 

RentnrKS 

Date  of  Last  Successful  Vaccination 

Two  simple  forms  for  notifying  the  parent  of  the  presence  of  some 
physical  defect  in  the  child  that  requires  attention  are  in  use  in  Somer- 
ville,  Mass.,  and  Ann  Arbor,  Mich.  Neither  one  has  any  "follow-up" 
provision  such  as  that  described  in  connection  with  the  New  York 
notification  card. 

The  Ann  Arbor  form  is  made  like  a  bank  check  with  a  stub  and  is 
perforated  for  separation.  These  forms  are  bound  in  a  book.  This 
plan  has  the  advantage  of  providing,  with  but  little  additional  work,  a 
record  of  the  notifications  sent. 


96  Medical  Inspection  of  Schools 

NOTIFICATION  TO  PARENTS,  SOMERVILLE,  MASS. 

(No.  9) 

THIS  NOTICE  DOES  NOT  EXCLUDE  THE  PUPIL  FROM  SCHOOL 

^omerbiUe  ^oarb  of  ^ealtd 

Medical  Inspection  Department 

Somerville, 190 

The  parent  or  guardian  of 

at is  hereby  informed  that  a  physical 

examination  by  the  medical   inspector  seems   to  show  the  following 
abnormal  condition: — 

You  are  advised  to  take  this  child  to  your  family  physician  for 
advice  and  treatment.  Very  respectfully, 

BOARD  OF  HEALTH. 


NOTIFICATION  TO  PARENTS,  ANN  ARBOR,  MICH. 


Ward Room 

Pupil's  Name 


Sent  by 
Address 
Note  . . 


Date. 


Ann  Arbor  Public  Schools 
Date 


Mr 

Dear 

It  has  come  to  our  notice  that  your, 
needs  medical  attention  relative  to 


and  we  would  suggest  that  you  place 

Under  the  Care  of  a  Physician  as  Early 

AS   Possible,  so  that will  be 

in  a  better  condition,  physically,  to  continue 

studies. 

Respectfully, 

ELLIOTT  KENT  HERDMAN,  M.  D., 
Board  of  Education.  Medical  Inspector 


Physical  Examinations  for  Non-Contagious  Defects    97 

-  There  is  one  branch  of  medical  inspection  which  has  been  given 
decided  attention  abroad,  but  until  very  lately  has  received  very  scant 
notice  in  this  country.  This  is  the  care  of  the  teeth  of  children.  In 
Germany  not  less  than  thirty  cities  support  free  dental  clinics  where 
work  is  done  on  the  teeth  of  school  children.  The  records  show  that 
this  has  resulted  in  a  great  improvement  in  the  health  of  the  children 
and  a  decided  diminution  of  absences.  Wherever  children's  teeth  are 
examined,  a  great  majority  are  found  to  be  suffering  from  more  or  less 
sierious  defects.  In  Germany,  where  account  is  taken  of  even  the 
smallest  imperfection,  the  per  cent,  of  the  defectives  is  reported  to  be 
as  high  as  96.  In  the  examinations  conducted  in  Dunfermline,  Scot- 
land, in  1907,  the  same  result  was  found.  Ninety-six  per  cent,  of  the 
children  are  reported  as  having  defective  teeth,  and  it  is  stated  that 
among  2200  pupils  of  the  schools  not  a  single  child  was  found  who  had 
had  dental  care  or  who  had  teeth  filled  or  otherwise  attended  to. 

There  is  some  indication  that  the  importance  of  sound  teeth  even 
in  small  children  is  commencing  to  be  realized  by  medical  inspectors 
in  America.  In  the  town  of  Northampton,  Massachusetts,  one  of  the 
blanks  used  by  the  medical  inspectors  is  a  small  chart  showing  in  out- 
line a  full  upper  and  lower  set  of  teeth.  By  making  marks  on  these 
pictured  teeth  the  medical  inspector  in  making  his  examination  indicates 
which  of  the  teeth  of  the  child  are  in  need  of  attention. 


TEETH  CHART,  NORTHAMPTON,  MASS. 
Name Address „ 


New  Bedford  and  Waltham  are  two  other  Massachusetts  cities 
where  attention  is  given  to  this  subject.  In  New  Bedford  the  children 
are  supplied  with  leaflets  containing  a  catechism  on  the  care  and  use 

7 


98  Medical  Inspection  of  Schools 

of  the  teeth.  The  leaflet  is  endorsed  by  the  Medical  Academy  of 
Dental  Science,  the  Dental  School  of  Tufts  College,  and  the  Dental 
School  of  Harvard  University. 


LEAFLET  ON  THE  CARE  OF  THE  TEETH  SUPPLIED  TO  THE 
CHILDREN,  NEW  BEDFORD,  MASS. 

What  are  the  teeth  for? 

Not  merely  for  ornament.  Their  chief  use 
is  to  prepare  the  food  for  the  stomach — to 
grind  the  food  and  mix  it  with  saliva.  Food 
vi^hich  is  not  thoroughly  chewed  causes  in- 
digestion and  constipation. 

How  long  should  the  teeth  last? 

To  the  end  of  life. 

How  do  we  lose  them? 

By  decay  and  loosening. 

What  causes  teeth  to  decay? 

Bits  of  food  and  candy  sticking  to  the  teeth ; 
also  a  poor  physical  condition. 

Where  does  the  food  lodge? 

All  along  the  edge  of  the  gums,  between  the 
teeth,  and  in  the  crevices  of  the  grinding 
surfaces. 

Can  decay  be  prevented? 
Yes,  to  a  large  extent. 

How  can  decay  be  prevented? 

By  scrubbing  the  teeth  thoroughly  with  a 
tooth-brush,  tooth-powder  and  water;  and 
by  keeping  up  the  general  health. 

How  often  should  the  teeth  be  cleaned? 

At  least  twice  a  day — after  breakfast  and  at 
bed  time.     Better  after  each  meal. 


Physical  Examinations  for  Non-Contagious  Defects    99 

Should  the  gums  be  brushed? 

Yes.     Moderate  friction  helps  to  keep  them 
healthy. 

How  often  should  tooth-powder  be  used? 

At  least  once  a  day — at  bed  time. 


Twice  a  year  at  least  a  Dentist  should 
carefully  examine  the  teeth. 

A  bad  condition  of  the  throat,  the  nose 
and  the  ears  is  made  worse  by  decayed 
teeth.  They  add  to  the  chances  of  catch- 
ing infectious  diseases.  Well  cared-for 
teeth  and  a  clean  mouth  help  prevent 
TUBERCULOSIS. 

Cleanliness  is  the  best  guard  against 
disease. 


Waltham  distributes  a  leaflet  on  the  care  of  the  teeth  to  the  parents 
of  the  school  children. 

LEAFLET  ON  THE  TEETH  AND  THEIR  CARE, 
WALTHAM,  MASS. 

To  Parents : — 

You  are  reminded  of  the  necessity  for  early  care  of 
children's  teeth.  With  such  care,  the  teeth  may  be  pre- 
served throughout  life.  This  will  not  only  save  much 
inconvenience  and  discomfort  in  later  life,  but  it  may 
enable  the  child  in  the  meantime  to  live  a  more  vigorous 
and  hence  a  more  successful  life. 

The  condition  of  the  teeth  has  much  to  do  with  the 
general  health. 

The    following    cautions,    abbreviated    from    those 


lOO  Medical  Inspection  of  Schools 

issued  to  teachers  and  school  physicians  by  the  Massa- 
chusetts board  of  education,  are  commended  to  your 
attention : 

Unclean  mouths  promote  the  growth  of  disease 
germs,  and  cavities  in  the  teeth  are  centers  of  infection. 

Irregularities  of  the  teeth,  especially  those  which  make 
it  impossible  to  close  the  teeth  properly,  thus  leading  to 
favilty  digestion  and  faulty  breathing,  should  receive  care- 
ful treatment. 

The  first  permanent  molars  are  perhaps  the  most  im- 
portant teeth  in  the  mouth.  They  come  at  about  the 
sixth  year  immediately  following  the  temporary  teeth,  and 
are  the  most  frequently  neglected  because  they  are  often 
mistaken  for  temporary  teeth. 

It  should  be  known  that  decay  of  the  teeth  is  caused 
primarily  by  the  fermentation  of  starchy  foods  and  sugars, 
and  that  the  greatest  factor  in  preventing  disease  of  the 
teeth  is  the  removal  of  food  particles  by  frequent  brushing. 
Children  should  be  prevented  from  eating  crackers  and 
candy  between  meals,  and  when  possible  the  teeth  should 
be  cleaned  after  eating.  Inspection  of  the  teeth  by  a 
dentist  should  be  made  at  least  once  or  twice  a  year. 

Youi  attention  is  also  called  to  the  prevalence  of 
maladies  of  the  nose  and  throat. 

The  health  of  a  child  and  his  ability  to  do  his  school 
work  may  be  seriously  impaired  by  the  presence  of  adenoid 
growths.  WTien  a  child  shows  obstruction  of  the  nose  by 
mouth  breathing,  snoring,  continual  discharge,  or  recurrent 
ear  trouble,  adenoids  should  be  suspected. 

Enlarged  tonsils,  recurrent  tonsillitis,  and  enlarge- 
ment of  the  glands  in  the  neck  also  constitute  a  serious 
handicap  to  the  child.  Either  condition  must  be  remedied 
before  he  can  have  a  fair  chance  in  the  world,  and  the 
earlier  the  better.  The  family  physician  should  be  con- 
sulted and  the  child  given  such  treatment  as  he  may  advise. 

Waltham,  Mass.,  vO 

Jan.  I,  1908, 


Physical  Examinations  for  Non-Contagious  Defects    loi 

It  is,  of  course,  of  the  utmost  importance  that  the  physical  defects 
disclosed  by  the  examination  of  the  school  physician  be  given  attention 
by  the  parents  of  the  child,  and  through  them  brought  before  a  physician 
and  remedied  if  possible.  It  is  of  very  slight  practical  utility  to  discover 
that  a  child  has  enlarged  tonsils  or  defective  vision  if  the  discovery 
results  merely  in  the  addition  of  one  to  the  statistical  table  of  the  defects 
discovered.  Unless  the  cases  are  followed  up,  and  unless  parents  can 
be  persuaded  or  coerced  into  having  their  children  given  the  necessary 
medical  attention,  it  is  obvious  that  a  large  proportion  of  the  work  of 
the  school  physician  in  making  the  examinations  will  be  of  scant  utility. 
Nevertheless,  despite  the  obvious  importance  of  ascertaining  whether 
physical  examinations  result  in  any  good,  attempts  made  to  discover 
and  report  the  number  of  cases  where  glasses  have  been  supplied  or 
medical  attention  given  are  few  in  number  and  ineffective  in  method. 

A  careful  examination  of  the  reports  of  the  superintendents  of  schools 
of  the  loo  largest  cities  of  their  country,  of  the  reports  of  the  superin- 
tendents of  schools  of  such  other  cities  as  are  known  to  have  systems 
of  medical  inspection,  and  of  a  large  number  of  magazine  and  newspaper 
articles  by  recognized  authorities,  fails  to  bring  to  light  a  single  official 
report  giving  the  three  essential  factors,  that  is,  total  number  of  children 
examined,  total  number  having  physical  defects,  and  total  number  of 
cases  where  the  parents  have  taken  steps  to  have  remedied  the  defects 
discovered.  Such  information  as  is  discovered  is  scant  and  indefinite. 
The  search  referred  to  above  has  brought  to  light  solely  the  following 
information :  The  Superintendent  of  Schools  of  Newton,  Mass.,  reports : 
"  In  every  case  in  which  the  defect  was  considerable  the  parents  of  the 
child  were  notified  and  advised  to  constilt  a  competent  oculist  or  the 
family  physician.  Very  many,  if  not  all,  responded,  to  the  great  benefit 
of  their  children." 

The  Superintendent  of  Schools  of  Somerville  says,  "At  least  600 
cases  have  been  professionally  treated  and  parents,  as  a  rule,  have 
gladly  cooperated  with  the  teachers."  He  does  not  state  from  how 
many  defective  children  the  600  cases  treated  came.  It  seems  proba- 
ble, however,  that  among  the  3753  cases  of  children  reported  examined 
in  1906,  600  received  professional  treatment.  If  this  interpretation  be 
correct,  it  means  that  15.9  per  cent,  received  the  needed  medical  treatment. 

The  City  Superintendent  of  Schools  of  New  York  City  says  in  his 


102  Medical  Inspection  of  Schools 

report  for  1907:  "Examinations  for  physical  defects  were  made  only 
in  248  schools,  less  than  one-half  the  total  number.  In  three-fourths 
of  the  cases  in  which  defects  were  found  the  examinations  conducted 
by  the  Department  of  Health  serve  only  for  the  purpose  of  piling  up 
useless  statistics."  If  these  statements  are  correct,  the  physical  examina- 
tions as  conducted  in  New  York  resvilt  in  about  one-sixth  of  the  children 
being  examined  and  about  25  per  cent,  of  those  examined  receiv- 
ing attention. 

The  most  definite  information  is  given  in  the  report  of  the  Superin- 
tendent of  Schools  of  Cleveland  for  1907.  In  this  city  the  Department 
of  Physical  Training  conducted  an  examination  of  30,000  children  in 
grades  three  to  seven  with  respect  to  the  condition  of  eyes,  ears,  nose 
and  teeth.  About  50  per  cent.,  or  15,000,  were  found  to  be  suffering 
from  physical  defects  more  or  less  serious.  Strenuous  endeavors  were 
made  to  secure  measures  looking  for  the  removal  or  alleviation  of  the 
defects  discovered.  By  the  cooperation  of  principals,  teachers,  dis- 
pensaries, physicians  and  parents  corrections  of  the  defects  were  secured 
in  3,388  cases,  or  22.5  per  cent. 

In  writing  of  the  medical  inspection  of  schools  in  Philadelphia  Dr. 
Walter  S.  Cornell,  Assistant  Medical  Inspector,  says: 

"The  obtaining  of  eye  glasses  by  the  children,  after 
official  recommendation,  follows  in  about  one-fourth  or 
one-fifth  of  all  cases  in  the  better  resident  sections,  where 
one  would  suppose  professional  advice  would  be  thankfully 
followed.  Among  the  poorer  classes  the  proportion  is 
about  one-third — under  \agorous  urging,  one-half.  Among 
the  foreign  population,  who  receive  official  recommenda- 
tions with  great  respect,  owing  to  their  ignorance  of 
English,  the  proportion  of  children  who  obtain  glasses, 
when  this  is  supervised  by  the  nurse,  is  in  my  own  district 
at  least  nine-tenths.  The  treatment  of  enlarged  tonsils  and 
adenoids  follows  recommendations  in  about  one-third  of 
the  cases.  The  better  classes  are  more  alive  to  the  evil 
consequences  following  these  conditions,  and  respond  fairly 
with  their  cooperation.  The  middle  and  poorer  classes 
appear    extremely    indifferent.     The    foreigners    usually 


Physical  Examinations  for  Non-Contagious  Defects   103 

go  to  the  nearest  dispensary,  but  their  dread  of  an  opera- 
tion deters  many  of  them  from  allowing  anything  but 
simple  local  treatments,  which  are  worthless.  The  other 
affections  are  remedied  in  probably  one-third  of  the  cases. 
The  contagious  cases,  of  course,  are  remedied,  since  action 
is  necessary  before  the  child  will  be  re-admitted  to  school." 

This  reference  to  the  proportionately  better  results  obtained  in 
poorer  sections  and  among  foreign  people  is  certainly  interesting  and 
far  from  flattering  to  American  pride.  Testimony  of  somewhat  similar 
nature  is  given  in  the  report  of  School  Nurses  of  Harrisburg,  Pa. : 

"The  white  children  of  American  parents  are  propor- 
tionately less  cleanly  in  person  and  dress  than  any  other 
class.  The  foreigners,  especially  the  Hungarians,  are  the 
most  cleanly.  The  negroes  are  almost  without  exception 
tidier  than  the  white,  and  in  exposed  parts  cleaner." 

To  sum  up  the  matter  of  physical  examinations  of  school  children 
for  the  detection  of  physical  defects,  we  are  confronted  by  the  great 
mass  of  evidence  showing  with  convincing  force  that  a  large  percentage 
of  all  school  children  are  suffering  from  physical  infirmities  which 
prevent  them  from  making  adequate  use  of  school  facilities.  The  pity 
of  it  is,  too,  that  practically  all  such  conditions  could  be  prevented  or 
cured  if  detected  early  in  life.  In  the  physical  examinations  by  trained 
physicians  a  means  is  offered  for  detecting  these  conditions,  and  with 
the  campaigns  of  education  now  being  vigorously  pushed  in  so  many 
parts  of  the  country  by  so  many  earnest  leaders,  social  machinery  for 
remedying  the  defects  discovered  must  soon  be  established. 


^ 


CHAPTER  VIII 

Vision  and  Hearing  Tests  by  Teachers 

There  is  considerable  divergence  of  opinion  among  authorities  on 
medical  inspection  as  to  whether  or  not  the  room  teacher  is  competent 
to  detect  signs  of  contagiovis  diseases  among  her  pupils.  There  is 
much  less  doubt  expressed  as  to  the  ability  of  the  room  teacher,  especially 
if  she  be  given  a  little  careful  training,  to  successfully  examine  her 
pupils  to  detect  the  presence  of  eye  troubles,  defective  hearing,  and 
even  the  presence  of  the  more  easily  detected  nose  and  mouth  defects. 

Under  the  provisions  of  the  Massachusetts  statute  (printed  in  full 
in  Chapter  XI  on  "The  Legal  Aspects  of  Medical  Inspection")  each 
teacher  is  required  to  examine  her  pupils  at  least  once  a  year  for  the 
pmrpose  of  testing  their  sight  and  hearing,  and  to  make  a  report  on  the 
results  found.  During  the  school  year  1907-8,  the  New  York  State 
Department  of  Health  is  conducting  a  similar  examination  in  the 
graded  schools  in  incorporated  villages  of  the  State. 

Somewhat  similar  work  is  being  done  by  the  State  Board  of  Health 
of  Utah. 

In  Connecticut  the  law  provides  that  teachers  shall  test  the  eyesight 
of  their  pupils  according  to  the  instructions  furnished  by  the  State 
Board  of  Education.  These  tests  are  made  triennially.  The  law 
provides  that  teachers  shall  notify  in  writing  the  parents  or  guardians 
of  pupils  found  to  have  any  defect  of  vision  or  disease  of  the  eyes,  and 
also  that  the  results  of  the  tests  shall  be  reported  to  the  State  Board  of 
Education, 

As  these  fovu  examinations  are  so  extensive,  are  conducted  imder 
State  authority,  and  are  the  result  of  careful  thought  and  preparation 
on  the  part  of  well-qualified  physicians  of  large  experience,  it  seems 
worth  while  to  give  here  a  somewhat  extended  account  of  the  Massa- 
chusetts system  and  to  show  also,  although  more  briefly,  what  is  being 
done  under  the  State  Boards  of  New  York,  Connecticut,  and  Utah. 

104 


Vision  and  Hearing  Tests  by  Teachers  105 

The  policy  of  the  legislators  of  the  State  of  Massachusetts  in  inserting 
into  their  statute  mandatory  provisions  that  the  tests  for  sight  and  hearing 
should  be  conducted  by  the  teachers  themselves,  rather  than  by  special- 
ists, has  evoked  many  expressions  of  surprise  and  some  of  criticism. 
These  provisions  were  inserted  on  the  recommendation  of  the  special- 
ists themselves,  who  deemed  that  such  tests  were  wholly  within  the 
capacity  of  the  teacher.  It  was  the  opinion  that  the  children  would  be 
subjected  to  a  less  nervous  strain  than  if  tested  by  a  stranger  and  wotild, 
therefore,  exhibit  themselves  in  a  more  natural  way.  It  is  the  intention 
of  the  Massachusetts  law  that  a  scientific  examination  by  specialists 
shall  be  made  in  cases  where  defects  are  apparently  revealed  by  the 
teacher's  tests. 

For  this  purpose  there  are  furnished  blanks  on  which  the  teachers 
notify  the  parents  of  apparent  defects  and  advise  consulting  a  specialist. 
During  the  first  year  that  the  law  was  in  operation,  the  returns  show 
that  such  notifications  have  been  sent  in  84,012  cases. 

During  the  hearings  before  the  State  Committee  on  Ways  and  Means 
when  the  Massachusetts  medical  inspection  bill  was  being  considered, 
a  mass  of  evidence  was  presented  by  experts  bearing  upon  the  question 
as  to  whether  or  not  such  examinations  could  be  successfully  conducted 
by  teachers.  The  high  standing  of  the  three  gentlemen  who  subscribed 
to  it  makes  the  following  opinion  particularly  significant: 

It  is  the  opinion  of  the  undersigned,  based  upon  pro- 
fessional experience,  that  school  teachers,  with  the  aid  of 
printed  directions  properly  prepared,  are,  because  of 
their  acquaintance  with  the  individual  children  under 
their  charge  and  their  subsequent  ability  to  communicate 
with  them  and  to  find  out  what  is  in  their  minds,  more  capa- 
ble of  making  a  satisfactory  examination  of  the  hearing  of 
such  children  than  a  doctor  other  than  a  specialist  called 
in  for  the  purpose  would  be  likely  to  be. 

(Signed)  Clarence  John  Blake,  M.D. 

D.  Harold  Walker,  M.D. 

William  F.  Knowles,  M.D. 

The  same  opinion  with  regard  to  eyesight  was  emphatically  ex- 
pressed by  Dr.  Myles  Standish,  who  represented  the  Massachusetts 


io6  Medical  Inspection  of  Schools 

Medical  Society  at  the  hearing,  as  it  was  also  by  Dr.  Charles  H.  Williams 
and  Dr.  O.  F.  Wadsworth.  It  is  the  nearly  universal  testimony  of 
experts.  In  "The  Sight  and  Hearing  of  School  Children,"  Dr.  David 
W.  Wells  says  in  regard  to  such  tests,  "The  lack  of  normal  vision  is 
quickly  determined,  and  probably  not  more  than  15  per  cent,  of  those 
needing  treatment  would  be  overlooked." 

In  "The  Necessity  for  the  Annual  Systematic  Examination  of 
School  Children's  Eyes,  Ears,  Nose,  and  Throats  by  School  Teachers," 
Dr.  Frank  AUport  says,  "Concerning  the  incompetency  of  teachers, 
I  have  only  to  say  that  any  one  who  is  competent  to  be  a  teacher  can 
make  the  tests  with  perfect  ease.  From  three  to  five  minutes  a  pupil 
is  all  the  time  that  is  required."  A  similar  opinion  is  strongly  ex- 
pressed by  Professor  Leslie,  who  has  conducted  extensive  and  successful 
work  in  the  Los  Angeles  public  schools.  In  the  Report  of  the  Superin- 
tendent of  Schools  for  1906-7  he  gives  the  following  account  of  this 
work  by  the  teachers : 

"In  this  work  the  schools  have  made  a  good  beginning. 
Throughout  the  grades  special  instruction  has  been  given 
to  principals  and  teachers  in  eye  and  ear  testing,  detection 
of  adenoid  growths  and  enlarged  tonsils;  and  corrective 
training  for  defective  chest  conditions  and  spinal  curvatiu"e 
has  been  emphasized.  Teachers  have  been  urged  to  study 
with  care  the  nutrition,  vitality,  and  endurance  exhibited 
by  individual  pupils,  especially  those  who  were  failing  or 
getting  on  poorly. 

"  In  the  graded  schools  the  only  apparatus  used  has  been 
Snellen's  Test  Types,  Pray's  Astigmatic  Charts,  and  the 
multiple  Maddox  rod. 

"The  eyesight  has  been  tested  and  the  visual  fraction 
for  each  eye  recorded.  The  hearing  has  been  tested  by 
either  watch  or  voice  test  and  the  pupils  seated  accordingly. 

"  In  a  part  of  the  schools  muscular  imbalance  has  been 
tested  in  case  of  those  pupils  showing  little  endurance,  who 
were  easily  fatigued,  or  otherwise  seemed  in  poor  working 
condition. 

"Reports  of  these  tests  for  all  the  schools  are  recorded 


Vision  and  Hearing  Tests  by  Teachers  107 

in  the  teachers'  registers.  Examination  of  these  reports 
justifies  the  statement  that  much  excellent  work  has  been 
done.  The  results  in  many  of  the  schools  tally  well  with 
results  obtained  in  certain  eastern  cities,  where  such  work 
has  been  done  by  persons  who  have  had  some  special 
training  along  these  lines. 

"  The  results  show  that  a  fair  degree  of  accuracy  can  be 
attained  by  the  average  teacher  if  she  will  give  careful 
attention  to  the  simple  tests  used. 

"The  difl&culties  experienced  by  many  teachers  largely 
disappear  when  simple  demonstrations  of  the  work  are 
given. 

"  For  this  purpose,  as  far  as  time  would  permit,  I  have 
asked  the  teachers  of  different  buildings  to  keep  defective 
children  at  the  close  of  school.  The  teachers  remaining 
and  working  with  me,  we  have  tested  these  children. 
After  such  testing,  teachers  have  completed  their  work  in 
this  line  with  much  more  certainty  and  assurance  and 
with  increased  interest  and  good  results. 

"Time  has  not  been  at  hand  to  carry  out  work  in  this 
particular  as  it  ought  to  be  done.  That  which  is  most  needed 
is  personal  help  to  the  teachers,  in  the  study  of  pupils." 

SIGHT  AND  HEARING  TESTS  IN  MASSACHUSETTS 

Vision  and  hearing  tests  are  made  in  accordance  with  the  following 
directions  prescribed  by  the  State  Board  of  Health.  The  materials 
for  the  tests  are  distributed  to  all  teachers  by  the  State  authorities. 

COMMONWEALTH  OF  MASSACHUSETTS 

Chapter  502,  Acts  of  1906 

Directions  for  Testing  Sight  and  Hearing  (Prepared  by 

the  State  Board  of  Health). 

To  Test  the  Eyesight 
Hang  the  Snellen  test  letters  in  a  good,   clear  light 
(side  light  preferred),  on  a  level  with  the  head.     Place 


io8  Medical  Inspection  of  Schools 

the  child  20  feet  from  the  letters,  one  eye  being  covered 
with  a  card  held  firmly  against  the  nose,  without  pressing 
on  the  covered  eye,  and  have  him  read  aloud,  from  left  to 
right,  the  smallest  letters  he  can  see  on  the  card.  Make  a 
record  of  the  result.  Children  who  have  not  learned 
their  letters,  obviously,  cannot  be  given  this  eyesight  test 
until  after  they  have  learned  them. 

(Note. — When  not  in  use,  the  chart  of  test  letters 
should  be  placed  in  the  envelope  in  which  it  is  sent,  to 
keep  it  from  becoming  soiled  and  illegible.  When 
damaged,  a  requisition  should  be  made  on  the  State  Board 
of  Education  for  a  new  chart.) 

To  Record  the  Acuteness  of  Eyesight 
There  is  a  number  over  each  line  of  test  letters,  which 
shows  the  distance  in  feet  at  which  these  letters  should  be 
read  by  a  normal  eye.  From  top  to  bottom,  the  lines  on 
the  card  are  numbered  respectively  50,  40,  30,  and  20. 
At  a  distance  of  20  feet  the  average  normal  eye  should 
read  the  letters  on  the  20-foot  line,  and  if  this  is  done 
correctly,  or  with  a  mistake  of  one  or  two  letters,  the  vision 
may  be  noted  as  f^,  or  normal.  In  this  fraction  the 
numerator  is  the  distance  in  feet  at  which  the  letters  are 
read,  and  the  denominator  is  the  number  over  the  smallest 
line  of  letters  read.  If  the  smallest  letters  which  can  be 
read  are  on  the  30-foot  line,  the  vision  will  be  noted  as 
f^;  if  the  letters  on  the  40-foot  line  are  the  smallest 
that  can  be  read,  the  record  will  be  f^;  if  the  letters 
on  the  50-foot  line  are  the  smallest  that  can  be  read,  the 
record  will  be  f  ^. 

If  the  child  cannot  see  the  largest  letters,  the  50-foot 
line,  have  him  approach  slowly  until  a  distance  is  found 
where  they  can  be  seen.  If  5  feet  is  the  greatest  distance 
at  which  they  can  be  read,  the  record  will  be  3^^  (-^^ 
of  normal). 

Test  the  second  eye,  the  first  being  covered  with  the 
card,  and  note  the  result,  as  before.     With  the  second 


Vision  and  Hearing  Tests  by  Teachers  109 

eye  have  the  child  read  the  letters  from  right  to  left,  to  avoid 
memorizing.  To  prevent  reading  from  memory,  a  hole  i^ 
inches  square  may  be  cut  in  a  piece  of  cardboard,  which 
may  be  held  against  the  test  letters,  so  as  to  show  only  one 
letter  at  a  time,  and  may  be  moved  about  so  as  to  show 
the  letters  in  irregular  order.  A  mistake  of  two  letters 
on  the  20  or  the  30-foot  lines,  and  of  one  letter  on  the  40 
or  50-foot  lines,  may  be  allowed. 

Whenever  it  is  found  that  the  child  has  less  than  normal 
sight,  f^,  in  either  eye,  that  the  eyes  or  eyelids  are 
habitually  red  and  inflamed,  or  that  there  is  a  complaint 
of  pain  in  the  eyes  or  head  after  reading,  the  teacher  will 
send  a  notice  to  the  parent  or  guardian  of  the  child,  as 
required  by  law,  that  the  child's  eyes  need  medical  atten- 
tion. 

Method  of  Testing  Hearing 

If  it  is  possible,  one  person  should  make  the  examina- 
tions for  an  entire  school,  in  order  to  insure  an  even 
method.  The  person  selected  should  be  one  possessed  of 
normal  hearing,  and  preferably  one  who  is  acquainted  with 
all  the  children,  the  announcement  of  an  examination 
often  tending  to  inspire  fear. 

The  examinations  should  be  conducted  in  a  room  not 
less  than  25  or  30  feet  long,  and  situated  in  as  quiet  a  place 
as  possible.  The  floor  should  be  marked  off  with  parallel 
lines  one  foot  apart.  The  child  should  sit  in  a  revolving 
chair  on  the  first  space. 

The  examination  should  be  made  with  the  whispered  or 
spoken  voice;  the  child  should  repeat  what  he  hears,  and 
the  distance  at  which  words  can  be  heard  distinctly  should 
be  noted. 

The  examiner  should  attempt  to  form  standards  by 
testing  persons  of  normal  hearing  at  normal  distances. 
In  a  still  room  the  standard  whisper  can  be  heard  easily 
at  25  feet,  the  whisper  of  a  low  voice  can  be  heard  from 
35  to  45  feet,  and  of  a  loud  voice  from  45  to  60  feet. 

The  two  ears  should  be  tested  separately. 


no  Medical  Inspection  of  Schools 

The  test  words  should  consist  of  numbers,  i  to  loo, 
and  short  sentences.  It  is  best  that  but  one  pupil  at  a  time 
be  allowed  in  the  room,  to  avoid  imitation. 

For  the  purpose  of  acquiring  more  definite  information 
concerning  the  acuteness  of  hearing,  one  may  have  recourse 
to  the  512  V.  s.  (vibrations  per  second)  tuning  fork  and 
the  Politzer  acoumeter. 

For  very  young  children  a  fair  idea  of  the  hearing  may 
be  obtained  by  picking  out  the  backward  or  inattentive 
pupils,  and  those  that  seem  to  watch  the  teachers'  lips, 
placing  them  with  their  backs  to  the  examiner,  and  asking 
them  to  perform  some  unusual  movement  of  the  hand, 
or  other  act. 

The  test  card  used  is  the  familiar  Snellen  chart.  A  reproduction  of 
the  form  used  by  the  Massachusetts  authorities  is  shown  on  page  iii. 

The  results  of  the  examinations  are  recorded  by  the  room  teacher 
on  double  sheets,  having  spaces  for  recording  the  results  of  the  examina- 
tion of  fifty  pupils.  A  reproduction  of  the  sheet  heading  is  given  on 
page  112. 

A  report  of  the  results  for  each  school  is  forwarded  to  the  superin- 
tendent by  the  teacher  or  principal. 


REPORT  OF  SIGHT  AND  HEARING  TESTS  TO  SUPERINTEN- 
DENT OF  SCHOOLS,  MASSACHUSETTS 

Commontnealtib  of  M^^^^tf^visittt^ 

Chap.  502,  Acts  of  1906 
Report  of  Sight  and  Hearing  Tests  to  Superintendent  of  Schools 

Town  1 

or      \ School, 

City  J 

190 

Number  of  Pupils  enrolled  in  the  school 

"       found  defective  in  eyesight 

"        found  defective  in  hearing 

"       of  parents  or  guardians  notified 

Teacher  or  Principal. 


Vision  and  Hearing  Tests  by  Teachers  iii 

SNELLEN  CHART  FOR  TESTING  EYESIGHT 

(Printed  on  heavy  white  cardboard,  size  ii  x  14  inches.) 
COMMONWEALTH  OF  MASSACHUSETTS. 

CHAPTER    502,    ACTS   OF    ipo6. 

SNELLEN'S  TEST  LETTERS  FOR  MEASURING  THE  ACUTENESS 

OF  VISION. 

50  Feet 


40  Feet 


o 


30  Feet 

O    T    P    E    C    L 


20  Feet 


L      D     E     C 


RECORD  OF  SIGHT  AND  HEARING  TESTS, 
MASSACHUSETTS 


nJ 

u 

CO 

H 

CO 

LlI 

H 

a 

<-* 

< 

u. 

IE 

'Ti 

tt?? 

u 

o 

^ 

h2 

Q 

-13 

v-^ 

o 

Z 

en 

o 

< 

<  g 

>s^» 

r-1 

<t-ii> 

^l^B 

RS 

CL 

H 

B 

o 

s 

< 

o 

a 

c75 

B 

Uh 

o 

O 
Q 

8 

cr: 

o 

u 


M 

< 

w 

a 

0) 

o 

a 

w 

•3 
•o 

IH 

c« 

0) 

.£! 
^t 
u 
o. 

1 

bo 

O 

< 

>> 
W 

M 

bO 
g 

s 

si 

a 

s 

0 
u 

a 

o 

a 
«> 

1 

a 

• 

Vision  and  Hearing  Tests  by  Teachers  113 

In  addition  to  these  reports,  the  teacher  is  required  to  notify  the 
parent  or  guardian  of  each  child  found  to  have  some  trouble  with  the 
ears  or  eyes.  Notification  cards  for  this  purpose  are  furnished  by  the 
State  Board. 


NOTICE  TO  PARENT  OR  GUARDIAN 

Commonhjealtj)  of  iWasisiacjjusietts; 

NOTICE  TO  PARENT  OR  GUARDIAN 

In  accordance  with  Chapter  502  of  the  Acts  of  1906  you  are  hereby  notified 

that  the  school  examination  of 

shows  that  there  is  some  trouble  with  the  g^es'   ^^^^'''^  needs  competent 
medical  advice.    Please  attend  to  this  at  once. 

Teacher 

190 


CommonttJealtfi  of  ittasJsiacljusiettjs 

NOTICE  TO  PARENT  OR  GUARDIAN 

In  accordance  with  Chapter  502  of  the  Acts  of  1906  you  are  hereby  notified 

that 

has  been  examined  by  me  as  school  physician  and  found  to  have  symp- 
toms of 

PLEASE  SECURE  COMPETENT  MEDICAL  ADVICE  AT  ONCE. 

School  Physician. 

190 

EYE  AND  EAR  EXAMINATIONS  AS  CONDUCTED  BY  THE 
NEW  YORK  STATE  DEPARTMENT  OF  HEALTH 

In  the  examinations  conducted  by  the  New  York  State  Department 
of  Health,  the  sight  test  cards  are  similar  to  the  ones  used  in  Massa- 
chusetts. As  the  instructions  issued  differ  somewhat  from  those  in  use 
in  the  New  England  State,  they  are  reproduced  in  full,  together  with 
the  blank  used  for  notifying  the  parents  of  defects  found  and  the  head- 
ing of  the  blank  xised  by  each  teacher  for  reporting  the  results  of  the 
examination  in  her  room. 


114 


Medical  Inspection  of  Schools 


TEACHERS'    INSTRUCTIONS   FOR   THE   EXAMINATION    OF 

THE  EYES  AND  EARS  OF  SCHOOL  CHILDREN, 

NEW  YORK  STATE 


NEW  YORK 

STATE  DEPARTMENT  OF  HEALTH 

ALBANY 


Teachers'   Instructions  for  the  Examination  of   the  Eyes  and 
Ears  of  School  Children 


I — Excep- 
tions 

2-3 — General 
Directions 


4 — Abnormal 
Conditions 


S— Test  for 

Normal 

Vision 

6 — Testing 

Distant 

Vision 


7 — Inability 
to  Name 
Letters 


EYES 

Children  under  7  years  need  not  be  examined. 

Children  wearing  glasses  should  be  tested  with  their 
glasses  properly  adjusted  to  their  faces. 

Children  should  be  examined  singly  and  privately. 

Ascertain  whether  the  child  habitually  suffers  from 
inflamed  lids  or  eyes  or  after  study  has  weariness  or  pain 
in  eyes  or  head  or  is  suffering  from  squint  (eyes  crossed). 

Find  whether  the  vision  is  normal  by  the  large  charts. 
Do  not  expose  the  charts  except  when  they  are  in  use,  as 
familiarity  leads  to  memorizing  the  letters. 

The  chart  should  have  a  good  side  illumination  and 
not  be  hung  in  range  of  a  window  which  will  dazzle  the 
eyes.  It  should  be  on  a  level  with  the  head  and  at  a 
measured  distance  of  20  feet  from  the  child,  who  should 
sit  facing  it.  Examine  each  eye  separately  by  holding  a 
card  or  other  screen  close  in  front  of  one  eye  while  the 
other  is  examined,  but  do  not  have  the  test  made  with 
one  eye  closed  by  pressure  or  otherwise.  Test  the  right 
eye  first  by  having  the  letters  named  in  order  from  the 
top  downward.  For  the  left  eye  have  the  letters  named 
from  right  to  left  to  avoid  repetition  from  memory. 

Where  the  child  cannot  name  the  individual  letters 
although  able  to  read,  the  chart  of  figiures  may  be  used. 
It  may  also  be  used  as  a  control  test.  If  the  child  does 
not  know  figures  or  letters  use  the  chart  of  inverted  E's, 


Vision  and  Hearing  Tests  by  Teachers  115 

asking  the  child  to  tell  by  the  movement  of  the  hand  the 
side  on  which  there  is  an  opening  in  the  E's  in  the  different 
lines,  i.  e.,  up,  down,  right  or  left. 

If  it  is  suspected  that  the  answers  are  being  made  8 — Memoriz- 
from  memory  a  hole  about  one  and  one-half  inches  may  ^^S 
be  cut  in  a  narrow  strip  of  cardboard  so  as  to  allow  only 
one  or  two  letters  to  show  through  the  hole,  and  by 
skipping  around  rapidly  it  is  easy  to  break  up  the  mem- 
orizing of  the  letters. 

The  lines  on  the  3  large  charts  are  numbered  200,   9 — Recording 
100,  70,  50,  40,  30,  20.     These  indicate  the  distance  the  Distant 
respective  letters  should  be  read  by  the  normal  eye.      ^^^^^ 
The  record  is  made  by  a  fraction,  of  which  the  numerator 
represents  the  distance  of  the  chart  from  the  child,  and 
the  denominator  the  lowest  line  he  can  correctly  read. 
Thus  if  at  20  feet  he  reads  the  lowest  line  the  vision  is  f  ^ 
or  normal.     If  he  only  reads  the  line  above,  the  vision 
is  f^  or  §  the  normal.     If  he  cannot  read  the  largest 
letter  he  must  go  slowly  toward  the  chart  vmtil  he  can. 
The  distance  he  is  from  the  chart  when  he  can  read  the 
largest  letter  will  be  the  numerator  and  200  the  denomi- 
nator.    Thus,  if  he  could  not  tell  the  letter  until  he  is  10 
feet  from  the  chart  his  vision  will  be  -^-^-^  or  -^-fj  the 
normal. 

The  eyes  should  also  be  tested  at  the  near  point  and   10 — Testing 

separately  as  with  the  large  chart,  the  scholar  being  seated   Near  Vision 

with  his  back  toward  the  light  and  with  the  small  chart   ^^  Focusing 

Power 
well  lighted.     Begin  at  18  inches  and  steadily  bring  the 

chart  nearer  and  nearer  while  the  scholar  continues  to 

read  aloud.     When  he  can  read  no  further  measure  the 

distance  from  his  eye  to  the  chart.     If  the  child  has 

difficulty  in  reading  the  chart  he  can  spell  the  words,  and 

the  test  will  be  determined  by  his  failure  to  pronounce 

the  letters  correctly. 

The  fractions  |^,  ||,  ^Vu,  etc.,  will  record  the  dis-   i"~Dist°nt" 
tant  vision  (20  feet)  of  each  eye.     Reads  right  eye  —   ^nd  Near 
inches  up  to  —  inches;  reads  left  eye  —  inches  up  to  —  Vision 


ii6 


Medical  Inspection  of  Schools 


inches  will  record  the  focusing  power  of  each  eye;    as, 
R.  E.  =  i6  up  to  4  in.;  L.  E.  =  15  up  to  3^  in. 


I — Excep- 
tions 
2 — Directions 

3 — Abnormal 
Conditions 


4 — Testing 
Hearing 


5 — Recording 
Hearing 


EARS 
All  children  should  be  examined. 

Children  should  be  examined  singly  and  privately. 

Ascertain  whether  the  child  has  frequent  earaches, 
has  pus  or  a  foul  odor  proceeding  from  either  ear,  suffers 
from  frequent  "colds  in  the  head,"  is  subject  to  a  con- 
stant catarrhal  discharge  from  the  nose  or  throat,  or  is  a 
mouth-breather. 

Seat  the  child  facing  you  near  one  end  of  a  quiet  room 
with  the  windows  closed  and  begin  the  test  of  the  hearing 
at  a  measured  distance  of  25  feet.  The  test  is  made  by 
having  the  left  ear  tightly  closed  with  the  finger  while 
you  observe  the  ability  of  the  child  to  repeat  your  moderate 
whispers  of  numbers  between  21  and  99  inclusive,  avoid- 
ing those  with  ciphers;  as,  75,  55,  37,  22,  etc.  Test  the 
left  ear  with  the  right  tightly  closed.  Avoid  having  a 
wall  behind  you  to  act  as  a  sounding  board.  The  figures 
should  have  as  nearly  equal  emphasis  as  possible,  and 
the  distance  at  which  the  child  correctly  repeats  a  series 
of  3  numbers  gives  his  hearing  distance  for  that  ear.  No 
further  test  is  necessary  if  the  child  hears  the  numbers 
perfectly  with  each  ear.  If  this  test  shows  a  slight 
defect  of  either  ear,  further  tests  may  be  made  by  observ- 
ing how  the  child  hears  the  tick  of  an  ordinary  watch, 
which  should  be  heard  normally  at  a  distance  of  not  less 
than  3  feet. 

The  hearing  is  recorded  by  a  fraction  of  which  the 
numerator  represents  the  distance  you  are  from  the  child 
and  the  denominator  is  25.  If  he  repeats  the  numbers 
correctly  at  25  feet  his  hearing  is  |-|  or  normal.  If  he 
only  repeats  the  numbers  correctly  when  you  are  at  20 
feet  it  is  ff  or  i  the  normal,  and  at  1 2  feet  -g-l,  etc. 


Vision  and  Hearing  Tests  by  Teachers  117 

CARDS  AND  REPORTS 

These   examinations   should   be   made  annually   in   i— Time 
October,  and  after  the  mid-winter  examinations  in  the 
case  of  new  pupils. 

All  the  charts  should  be  kept  without  rolling  or  being  2 — Charts 
folded,  in  a  clean  dark  place  to  prevent  the  yellowing  of 
the  paper. 

Send  at  once  a  properly  Med  blank  to  the  parent  or  3 — Reports  to 

guardian  of  all  children  whose  vision  is  less  than  |-g-,  in  Parents  or 

either  eye.     Do  not  fail  to  report  cases  where  the  vision  Guardians 

is  f^,  if  the  child  is  backward  in  school  work,  suffers  <^^y®  ^on- 
from  any  abnormal  condition  of  the  lids,  inflamed  eyes, 
has  a  discharge  from  either  eye  or  frequent  headaches. 

Report  all  cases  where  the  hearing  with  either  ear  ^  ^^j.  cq^. 
falls  below  normal,  or  the  child  suffers  from  any  of  the  ditions 
conditions   mentioned   under  "Abnormal   Conditions 
—Ears." 

Mail  to  the  State  Department  of  Health  a  report  4 Health 

giving   the   name   and   age   of   all   children   examined.  Department 
Where  the  distant  vision  is  f^,  the  focusing  power  18  Reports 
inches  up  to  4  inches,  and  there  are  no  abnormal  condi- 
tions of  the  eye  or  lids,  or  headaches;    and  where  the 
hearing  is  normal  in  each  ear,  without  any  other  abnormal 
condition,  leave  the  spaces  opposite  such  names  vacant. 

The  vision  and  hearing  are  recorded  in  the  proper 
spaces  for  each  by  fractions  as  explained  above.  All 
abnormal  conditions  of  the  eyes,  lids,  ears,  nose,  throat, 
and  headaches  are  to  be  recorded  by  proper  abbrevia- 
tions under  the  respective  headings. 

This  report  must  be  filed  with  the  Department 
within  10  days. 

EUGENE  H.  PORTER,  M.D., 

Commissioner  0}  Health 


Town. 


NEW  YORK  STATE  BOARD  OF  HEALTH, 
REPORT  OF  TEACHER 

District 


No. 


1 

2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 
30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
40 
41 
42 
43 
44 
45 


Name. 


Age. 


Distant 
Vision. 
(20  feet.) 


R.  E.      L.  E 


Focusing 
Power. 

(Inches.) 


R.  E.      L.  E 


Eyes. 

Inflam 
Disch. 
Squint. 


LIDS. 

Inflam. 

Scaly. 

Swollen. 


Eyes. 

Pain. 
Fatigued 
after  use. 


ii8 


School 

Head- 
ache. 

Daily 
Weekly, 


Grade. 


Hearing. 


R.  E.      L.  E. 


Ear. 


Pain. 


Ear. 


Disch. 
Odor. 


NOBE. 


Colds, 
Catarrh. 


Throat. 


Mouth- 
breather. 


Cases 
Reported 

to 

Parents 

or  Guard- 


Gen.  Hbalth. 


Remarks. 


119 


120  Medical  Inspection  of  Schools 

BLANK  USED  FOR  NOTIFYING  PARENTS,  NEW  YORK  STATE 

Public  School  No 

190 

Mr 

*  eyes 
*  son 

ears       ,      ,  r     • 
An  examination  of  your  dausrhter  shows  the  to  be  defective 

•'  °  nose 

throat 

and  below  the  standard  required  by  the  State  Department  of  Health. 

This  child  cannot  do  satisfactory  work  in  school  until  this  defect  is 
corrected. 

You  should  consult  with  your  family  physician  or  with  the  health 
officer  of  the  village  as  to  the  choice  of  an  eye  or  ear  doctor  whom  you 
are  advised  to  consult  about  the  trouble. 

Teacher. 

*  Strike  out  the  words  not  required. 

EYESIGHT  TESTS  CONDUCTED  BY  THE  STATE  BOARD  OF 
EDUCATION  OF  CONNECTICUT 

Eyesight  tests  are  conducted  by  the  State  Board  of  Education  of 
Connecticut  under  the  provisions  of  Section  2251  of  the  general  statute. 
This  section  reads  as  follows : 

The  State  Board  of  Education  shall  prepare  or  cause  to 
be  prepared  suitable  test  cards  and  blanks  to  be  used  in 
testing  the  eyesight  of  the  pupils  in  public  schools,  and 
shall  furnish  the  same,  together  with  all  necessary  instruc- 
tions for  their  use,  free  of  expense,  to  every  school  in  the 
state.  The  superintendent,  principal,  or  teacher,  in 
every  school,  during  the  fall  term  in  the  year  1904  and 
triennially  thereafter,  shall  test  the  eyesight  of  all  pupils 
under  his  charge  according  to  the  instructions  furnished, 
and  shall  notify  in  writing  the  parent  or  guardian  of  every 
pupil  who  shall  be  found  to  have  any  defect  of  vision  or 


Vision  and  Hearing  Tests  by  Teachers  121 

disease  of  the  eyes,  with  a  brief  statement  of  such  defect 
or  disease,  and  shall  make  written  report  of  all  such 
cases  to  the  State  Board  of  Education, 


INSTRUCTIONS 

The  following  instructions,  prepared  by  S.  B.  St.  John,  M.D.,  of 
Hartford,  give  a  method  of  intelligently  making  the  tests  required  by 
the  law  and  also  indicate  the  form  of  reports  to  parents  and  the  State 
Board  of  Education: 

Separate  Test  for  Each  Eye 

In  testing  the  eyesight  with  the  large  chart  (I),  each 
eye  should  be  tested  separately,  the  other  eye  being 
covered  with  a  screen  and  both  eyes  being  open. 

Light 

The  chart  should  be  himg  in  a  good  light,  preferably 
a  side  illumination,  and  not  in  range  with  a  window  (which 
might  dazzle  the  eyes  of  the  child). 

Method 
Seat  the  child  at  a  measured  distance  of  20  feet  from  the 
chart  and  cover  one  eye  with  a  pasteboard  screen.  Have 
him  pronounce  aloud  the  letters,  beginning  at  the  top,  and 
reading  from  left  to  right,  and  note  the  lowest  line  that  he 
reads  correctly.  Repeat  the  test  for  the  other  eye,  but 
have  him  reverse  the  order  and  read  from  right  to  left  (or 
backwards),  to  avoid  the  danger  of  repeating  from  memory. 

Record 

To  record  the  visual  power  thus  obtained  notice  that 
the  lines  are  numbered  200,  100,  70,  50,  40,  30,  and  20. 
These  numbers  indicate  the  distances  at  which  the  respec- 
tive letters  shovdd  be  read  by  a  normal  eye.  The  record 
is  made  by  a  fraction,  of  which  the  numerator  represents 
the  distance  from  the  child  to  the  card  and  the  denominator 
the  lowest  Hne  he  can  correctly  read.     Thus  if  at  20  feet 


STATE  OF  CONNECTICUT,  EYESIGHT  TEST, 
CHART  I 

(Printed  on  heavy  white  cardboard,  size  9  x  20  inches.) 


200 


100 


70 


ffl 


50 


40 


30 


20       H  ^  li  iS  B  S5 


1^  PRBDKKOF 


Vision  and  Hearing  Tests  by  Teachers  123 

he  reads  the  lowest  line  the  vision  is  f  ^  or  i  =  normal. 
If  he  only  reads  the  line  above,  the  vision  is  |^  or  §  normal. 
If  he  cannot  read  the  largest  letter  at  20  feet,  he  must  go 
slowly  toward  the  card  until  he  can  read  the  largest  letter. 
The  distance  from  him  to  the  card  (as  before)  will  be  the 
numerator  and  200  the  denominator.  Thus,  if  he  could 
not  tell  the  letter  until  he  was  10  feet  from  the  card  his 
vision  =  -^"-j,  or  ^V  of  normal. 


TEST  OF  FOCUSING  POWER 

STATE     OF    CONNECTICUT,    EYESIGHT    TEST, 

CHART  II 

(Printed  on  heavy  white  cardboard,  size  6x8  inches.) 

State  of  Connecticut 

EYESIGHT  TEST 

Chart  II 

was  born  at  York  on  the  first  of  March  in  the  sixth  year  of  the  reign  of  King  Charles  the  First.  From  the  time  when 
was  quite  a  voung  child,  I  had  felt  a  great  wish  to  spend  my  life  at  sea.  and  as  I  grew,  so  did  this  taste  grow  more  and 
more  strong;  till  at  last  1  broke  loose  from  mv  school  and  home,  and  'ound  mr  x'ay  on  foot  to  Hull,  where  I  soon  got  a 
place  on  board  a  ship.  When  we  had  set  sail  but  a  few  days,  a  squall  of  wind  came  on,  and  on  the  fifth  night  we  sprang  a 
leali.  All  hands  were  sent  to  the  pumps,  but  we  felt  the  ship  groan  in  all  her  planks,  and  her  beams  quake  from  stem  to 
stern;  so  that  it  was  soon  quite  clear  there  was  no  hop-?  for  her.  and  thai  all  we  could  do  was  to  save  our  lives.  The  first 
thing  was  to  fire  offguns,  to  show  that  we  were  in  need  o''  help,  and  -.t  length  a  ship,  which  lay  not  far  from  us,  sent  a  boat 
to  oar  aid.  But  the  sea  was  too  rough  for  it  to  lie  near  our  ship's  side,  so  we  threw  out  a  rope,  which  the  men  in  the  boat 
canght,  and  made  fast  and  by  this  means  we  all  ;oi  '.n.  Still,  iu  so  wild  a  sea  i'  wa'^  in  vaiu  to  try  to  geiou  board  the  ship 
which  had  sent  out  the  men,  or  to  use  our  oars  in  the  boat,  and  all  we  could  do  was  to  let  it  drive  to  shore.  In  the 
■pace  of  half  an  hour  our  own  ship  struck  on  a  rock  and  went  down  and  we  saw  her  no  more.  We  made  but  slow  way  to 
the  land,  of  which  we  canght  sight  now  and  then  when  the  boat  rose  to  the  top  of  some  high  wave,  and  there  we 


The  chart  (II)  of  fine  type  is  for  testing  the  focusing 
power.  In  normal  eyes  the  focusing  power  varies  with 
age.  Up  to  lo  years  the  normal  eye  will  read  up  to  2^ 
inches;  at  12,  up  to  2J;  at  15,  up  to  3,  and  at  20,  up  to 
3|.  The  focusing  power  may  be  affected  by  temporary 
conditions,  and  variations  from  the  normal  figures  are 
important  only  when  marked  and  constant. 

The  eyes  should  be  tested  separately,  as  with  the 
large  chart,  the  scholar  being  seated  with  his  back  to- 
ward the  light,  but  not  so  much  as  to  shade  the  card. 
Begin  at  12  inches  and  steadily  but  slowly  bring  the  card 


CHART  OF  GRADUATED   FIGURES,   STATE   OF 
CONNECTICUT,  EYESIGHT  TEST,  CHART  III 

(Printed  on  heavy  white  cardboard,  size  9  x  20  inches.) 


100 


f>-~->^^M|^™l 


70  [ 


i^Pmk!         I^W         !Mftl£.        l^WLl 

^^B  M  B  M 


^o  mmmmm 


i    S 


20  BmmEmm  & 


15   623094538260 


124 


CHART  OF  E's,  STATE  OF  CONNECTICUT,  EYE- 
SIGHT TEST,  CHART  IV 

(Printed  on  heavy  white  cardboard,  size  9  x  20  inches.) 


200 


100 


70 


50 


30  m  ua  s  E  m 


20     ly  m  E  m  a  E 


15  B  a  ra  B  Q  E  B 


126  Medical  Inspection  of  Schools 

nearer  while  the  scholar  continues  to  read  aloud;  when 
his  hesitancy  shows  that  he  is  not  seeing  correctly, 
measure  the  distance   from    his    eye   to    the   card,    and 

record  "  Reads  up  to inches  with  R.  eye." 

Repeat  this  test  for  the  other  eye  and  then  for  both 
eyes. 

If  it  is  uncertain  whether  the  hesitancy  in  reading 
arises  from  indistinct  seeing  or  inability  to  pronounce 
the  word,  ask  the  scholar  to  tell  the  instant  when  the 
letters  begin  to  be  confused  and  measure  the  distance 
then. 

The  chart  of  graduated  -figures  (III)  is  to  be  used  in 
cases  where  the  scholar  knows  figxires  and  does  not  know 
letters. 

The  chart  covered  with  E's  (IV)  is  for  those  who  know 
neither  letters  nor  figures.  The  teacher  should  stand  by 
the  chart  and  point  out  the  different  characters,  asking 
which  is  the  "open  side,"  i.  e.,  whether  it  opens  up,  down, 
right,  or  left.  It  is  better  to  have  the  scholar  indicate  the 
open  side  by  a  gesture  of  the  hand  in  the  direction  corre- 
sponding to  that  side.  The  details  of  the  use  of  charts 
III  and  IV  are  the  same  otherwise  as  of  that  containing 
letters. 

Use  of  Charts 

The  charts  should  not  be  hung  in  the  schoolroom 
when  not  in  use,  as  the  scholars  very  readily  memorize 
them,  which  vitiates  the  examination.  If  the  teacher 
suspects  that  the  answers  are  being  made  from  memory, 
a  hole  about  i^  inches  square  may  be  cut  near  the  end 
of  a  narrow  strip  of  cardboard,  and  this  may  be  used  to 
cover  the  lines,  exposing  only  one  or  two  letters  at  a  time 
through  the  hole.  By  skipping  around  rapidly  with  this 
device  it  is  easy  to  break  up  the  memorizing  trouble. 


Vision  and  Hearing  Tests  by  Teachers  127 

REPORTS 

The  following  are  forms  of  reports : 


Teacher's  Report  to  Parent  or  Guardian,  Blank  i. 


Eyesight  test 
blank  i 


REPORT  TO  PARENT  OR  GUARDIAN 

BY  TEACHER 

Town District School 


190 . 

To 


You  are  hereby  notified  that  the  examination  of  the  eyes  of 

[name] 
shows  that  they  are — [Here  describe  the  condition  in  simple  terms,  whether  sore, 
discharging  matter,  watery,  or  of  strained  appearance.     If  none  of  these  conditions 
exist,  cancel  this  section.] 


The  examination  of  the  eyesight  shows  that  it  is  defective  in  <  ,     ,    >  eyes.     The 

defect  is  such  that  in  the  Right  eye  the  sight  power  is  *  [give  fractional  form  as  deter- 
mined by  tests]  of  what  it  should  be,  while  in  the  Le^t  eye  it  is  ' 

You  are  advised  to  take to  a  physician  as  soon 

as  possible  to  ascertain  what  is  the  trouble,  whether  it  can  be  remedied,  and  whether 

<    ,      >  should  continue  to  go  to  school. 

Teaclur. 


128  Medical  Inspection  of  Schools 

Teacher's  Report  to  State  Board  of  Education,  Blank  ii. 

Eyesight  test 
blank  ii 

REPORT  TO  STATE  BOARD  OF  EDUCATION 

BY   TEACHER 

Scholar 

Town District School 

190 

Name Age 

General  condition  of  health 

General  appearance  of  eyes  [whether  red,  watery,  or  discharging  material  thicker 
than  water], 

General  appearance  of  eyelids  [whether  red,  swollen,  or  covered  with  crusts], 

Resttlts  of  Testing  (at  20  feet  with  chart). 

Vision  of  right  eye  = Vision  of  left  eye  = 

Results  of  Testing  (with  small  type). 

With  right  eye,  nearest  point  at  which  the  diamond  type  can  be  read  is 

inches.     With  left  eye inches.     With  both  eyes  reads  up  to inches 


Teacher. 


Report  to  State  Board  of  Education,  Blank  iii. 


Eyesight  test 
blank  iii 


REPORT  TO  STATE  BOARD  OF  EDUCATION 

BY  SUPERINTENDENT,  PRINCIPAL  OR  TEACHER 

School 

Town .         District 

School Department 

Number  enrolled  in  school 

[schools] 

Number  tested 

Number  blanks  sent  to  parents 


Remarks. 


Superintendent 

Date, Principal  or 

Teaciier 


Vision  and  Hearing  Tests  by  Teachers  129 

SUGGESTIONS 

Blank  i  should  be  sent  to  parents  only  when  some  defect  of  eyesight  is 
discovered  by  the  test.  No  blank  is  to  be  sent  when  the  eyesight  is  normal. 

When  blank  i  is  sent  to  parents,  blank  ii  should  be  sent  to  the  State 
Board  of  Education. 

When  the  eyesight  of  all  pupils  in  the  school  has  been  tested,  superin- 
tendents, principals,  or  teachers  are  requested  to  send  to  the  State 
Board  of  Education  the  general  blank  iii  showing  the  whole  number 
of  scholars  tested. 

For  blanks  or  information  address 

State  Board  of  Education, 

Hartford. 

EXAMINATIONS  OF  THE  STATE  BOARD  OF  HEALTH 

OF  UTAH 

In  Utah,  cards  similar  to  those  in  use  in  Massachiisetts  and  New 
York  are  furnished  for  the  testing  of  eyesight.  The  instructions  fur- 
nished teachers,  together  with  a  reproduction  of  the  report  blank  filled 
in  by  the  principal  of  the  school  and  forwarded  to  the  State  Board  of 
Health,  follow. 

Instructions  for  the  Examination  of  School  Chil- 
dren's Eyes  and  Ears,  etc. 

(After  the  Method  Proposed  by  Dr.  Frank  Allport,  of  Chicago,  111.) 
For  Use  of  Principals,  Teachers,  etc. 

Do  not  expose  the  card  except  when  in  use,  as  familiarity 
with  its  face  leads  children  to  learn  the  letters  "by  heart." 

First  grade  children  need  not  be  examined. 

The  examinations  shoiild  be  made  privately  and  singly. 

Children  already  wearing  glasses  should  be  tested  with 
such  glasses  properly  adjusted  on  the  face. 

Place  the  "Vision  Chart  for  Schools"  (Snellen's)  on  the 
wall  in  a  good  light ;  do  not  allow  the  face  of  the  card  to  be 
covered  with  glass. 

The  line  marked  XX  (20)  should  be  seen  at  twenty 
feet,  therefore  place  the  pupil  twenty  feet  from  the  card. 

Each  eye  should  be  examined  separately. 

Hold  a  card  over  one  eye  while  the  other  is  being  ex- 
9 


130  Medical  Inspection  of  Schools 

amined.     Do  not  press  upon  the  covered  eye,   as  the 
pressure  might  induce  an  incorrect  examination. 

Have  the  pupil  begin  at  the  top  of  the  test  card  and  read 
down  as  far  as  he  can,  first  with  one  eye  and  then  with 
the  other. 

Facts  to  Be  Ascertained 

1.  Does  the  pupil  habitually  suffer  from  inflamed  lids  or 

eyes? 

2.  Does  the  pupil  fail  to  read  a  majority  of  the  letters  in 

the  number  XX  (20)  line  of  the  Snellen's  Test 
Types  with  either  eye  ? 

3.  Do  the  eyes  and  head  habitually  grow  weary  and 

painful  after  study  ? 

4.  Does  the  pupil  appear  to  be  "cross-eyed"? 

5.  Does  the  pupil  complain  of  earache  in  either  ear? 

6.  Does  matter  (pus)  or  a  foul  odor  proceed  from  either 

ear? 

7.  Does  the  pupil  fail  to  hear  an  ordinary  voice  at  twenty 

feet  in  a  quiet  room?  Each  ear  should  be  tested 
by  having  the  pupil  hold  his  hand  over  first  one  ear, 
and  then  the  other.  The  pupil  should  close  his 
eyes  during  the  test. 

8.  Is  the  pupil  frequently  subject  to  "colds  in  the  head" 

and  discharges  from  the  nose  and  throat  ? 

9.  Is  the  pupil  an  habitual  "mouth  breather"? 

If  an  afl&rmative  answer  is  found  to  any  of  these  ques- 
tions, the  pupil  should  be  given  a  printed  card  of  warning 
to  be  handed  to  the  parent,  which  should  read  something 
like  this : 

Card  of  Warning  to  Parents 

After  due  consideration  it  is  believed  that  your  child 
has  some  Eye,  Ear,  Nose  and  Throat  disease,  for  which 
your  family  physician  or  some  specialist  should  be  at 
once  consulted.  It  is  earnestly  requested  that  this 
matter  be  not  neglected. 

Respectfully, 

School. 


Vision  and  Hearing  Tests  by  Teachers  131 

If  only  an  eye  disease  is  suspected,  the  words  "  ear, 
nose  and  throat"  should  be  crossed  off;  if  only  an  ear 
disease  is  suspected,  the  words  "eye,  nose  and  throat" 
should  be  crossed  off;  if  it  is  only  a  nose  and  throat  dis- 
ease, the  words  "eye  and  ear"  should  be  crossed  off. 

It  will  be  observed  that  these  cards  are  non-obligatory 
in  their  natiure.  They  do  not  require  anything  of  the 
parent,  who  is  at  perfect  liberty  to  take  notice  of  the 
warning  card  or  not,  as  he  sees  fit.  They  simply  warn 
the  parent  that  a  probable  disease  exists,  thus  placing  the 
responsibility  upon  the  parent. 

Nevertheless,  if  parents  neglect  the  warning  thus 
conveyed,  the  teacher  should,  from  time  to  time,  en- 
deavor to  convince  such  parents  of  the  advisability  of 
medical  counsel.  Teachers  are  urged  to  impress  upon 
pupils  and  parents  the  necessity  for  consulting  reputable 
physicians. 

These  tests  should  be  made  annually  at  the  begin- 
ning of  the  fall  term,  and  should  include  all  children 
above  the  first  grade. 

Each  teacher  should  examine  all  the  children  in  his  or 
her  own  room,  and  should  report  the  results  of  such  ex- 
aminations to  the  principal,  such  report  to  be  signed  by 
the  examining  teacher. 

The  following  simple  form  of  report,  to  be  filled  out 
by  the  teacher  and  handed  to  the  principal,  is  suggested 
and  may  be  printed  upon  paper  of  any  size  and  character 
that  is  deemed  advisable  by  the  local  and  school  au- 
thorities, and  should  be  distributed  to  the  different  room 
teachers : 


No. 

Name  of  Pupil. 

Do  THE  Tests  Indicate  an  Eye,  Ear, 
Nose  OR  Throat  Disease?  Answer 
"Yes  "or  "No."    If  so,  which? 

Was      the      Pupil 
Given   a    Card    of 
Warning  ? 

I 
2 

3 
4 

John  Doe 
Robert  Smith 
Mary  Brown 
Edward  Hart 

Yes ;  eye 

Yes ;  ear 

No 

Yes  ;   nose  or  throat 

Yes. 
Yes. 
No. 
Yes. 

132  Medical  Inspection  of  Schools 

Report   to   State   Board   of  Health   of  Utah,   of  Eye,  Ear  and 

Throat  Tests 

Report    to  State  Board  of    Health  of  Eye,  Ear   and    Throat 
Tests  of  Pupils  in  Public  Schools 


Date 

Place 

Name  or  Number  of  School 

Grade  of  Pupils 

Name  of  Piincipal 

Name  of  Teacher 

Number  of  Pupils  in  room 

Number  of  Pupils  tested 

Nimiber  of  Pupils  wearing  glasses 

Number  of  Pupils  free  from  symptoms  of  eye,  ear,  nose  and  throat 
disease 

Number  of  Pupils  suspected  of  having  defective  sight  or  eye  disease 
in  addition  to  those  wearing  glasses 

Number  of  pupils  suspected  of  having  defective  hearing  or  disease 
of  ears  

Number  of  Pupils  suspected  of  having  disease  of  nose  or  throat 

Has  notification  been  sent  to  parents  in  each  case  where  defect  is  sus- 
pected ? 

Remarks  by  Teacher  or  Principal 


Note. — This  report  should  be  mailed  to  the  State  Board  of  Health  promptly  after 
tests  have  been  made. 


Vision  and  Hearing  Tests  by  Teachers 


133 


In  the  city  of   Ogden  there  are  three  more  interesting  blanks  used 
in  connection  with  these  tests. 

The  first  is  the  report  of  the  teacher  to  the  principal. 


Teacher's  Report  to  Principal,  Ogden,  Utah 

TEACHER'S  REPORT  TO  PRINCIPAL. 


No. 

Nave  of  Pupil. 

Do  the  tests  indicate  an  Eye,  Ear, 

Nose  or  Throat  Disease  ? 

Answer  "  Yes  "  or  "  No." 

If  so,  which  ? 

Was  the  Pupil 

given 

a  Card  of 

Warning? 

The  results  of  examinations  and  tests  are  made  known  to  parents 

by  means  of  a  card  of  warning: 


Card  of  Warning  to  Parents,  Ogden,  Utah 

CARD  OF  WARNING  TO  PARENTS. 
As  a  result  of  examination  and  tests  made  under  instructions  from 
the  State  Board  of  Health,  it  is  believed  that  your  child  has  some  Eye, 
Ear,  Nose  and  Throat  disease,  for  which  your  family  physician  or 
some  specialist  should  be  at  once  consulted.  It  is  earnestly  requested 
that  this  matter  be  not  neglected. 

Respectfully, 


Teacher 

Many  serious  consequences  result  from  uncorrected  defects  of 
sight  and  hearing  in  school  children,  also  from  mouth  breathing,  which 
is  usually  caused  either  by  an  obstruction  in  the  nose  or  by  the  pres- 
ence of  adenoids.  It  is  extremely  important  that  defects  of  vision  shall 
be  corrected  by  properly  fitted  glasses  and  that  any  condition  causing 
mouth  breathing  shall  be  promptly  removed  by  proper  treatment. 


134  Medical  Inspection  of  Schools 

The  third  blank  in  use  in  the  Ogden  schools  is  of  special  interest 
because  it  is  almost,  if  not  entirely,  unique  among  the  blanks  used  in 
American  school  systems.  It  is  a  blank  on  which  the  teacher  requests 
from  the  parent  an  explanation  of  the  absence  from  school  of  a  pupil 
and  on  which  the  parent  writes  the  excuse.  On  the  reverse  are  printed 
the  rules  governing  absence  and  tardiness. 


Teacher's  Request  upon  Parent  for  Explanation  of  Absence  of 
Pupil,  Ogden,  Utah 

Ogden  Public  Schools 

Ogden,  Utah, 190 

M 

Your 

has  been  absent  from  school  as  follows : 


for  which  a  sufficient  excuse  should  be  given. 

Teacher 

(WRITE  EXCUSE  BELOW) 


Parent 

SEE  OTHER  SIDE 


Vision  and  Hearing  Tests  by  Teachers  135 

Rules  Governing  Absence  and  Tardiness 


7.  Pupils  are  required  in  all  cases  of  absence  to  bring, 
on  their  return  to  school,  an  excuse  in  writing  from  their 
parents  or  guardians,  assigning  good  and  sufficient  reasons 
for  such  absence.  The  only  valid  excuses  for  such 
absence  are:  (i)  Sickness  of  the  pupil;  (2)  Sickness  or 
death  of  some  member  of  the  family  requiring  the  presence 
of  the  pupil  at  home  or  making  it  impossible  to  send  the 
pupil  promptly;  (3)  Inclement  weather,  when  sending  the 
pupil  would  endanger  his  or  her  health. 

8.  Pupils  must  bring  written  excuse  from  parent  or 
guardian  for  tardiness,  unless  the  cause  of  same  be  known 
to  the  teacher.  Two  times  tardy  is  equal  to  one-half 
day's  absence. 

9.  For  violation  of  any  of  the  foregoing  rules  the 
principal  may  temporarily  suspend  a  pupil  from  school 
and  thereupon  shall  immediately  inform  the  parent  or 
guardian  of  the  fact  and  the  cause  therefor,  and  also 
report  the  case  to  the  Superintendent.  On  second  sus- 
pension of  such  pupil  for  the  same  offense,  he  shall  not  be 
permitted  to  return  without  a  special  permit  from  the 
Board. 


The  methods  advocated  by  the  State  Boards  of  Health  of  Massa- 
chusetts, New  York,  and  Utah,  and  the  State  Board  of  Education  of 
Connecticut,  by  which  teachers  can  test  their  pupils  for  defects  of 
eyesight  and  hearing,  have  been  described  at  length,  because  it  is  gen- 
erally recognized  that  with  slight  training  teachers  are  competent  to 
conduct  such  tests.  It  is  even  claimed  that  there  is  an  advantage  in 
having  them  made  by  teachers,  becavise  parents  will  not  accept  the 
diagnosis  as  authoritative  and  will  consult  specialists  as  to  the  alleged 
troubles  found.  There  can  be  no  doubt,  too,  that  making  such  tests 
awakens  teachers  to  a  quickened  interest  in  the  bearing  of  ph}'sical 
defects  on  school  progress,  gives  them  a  closer  insight  into  the  charac- 


136  Medical  Inspection  of  Schools 

teristics  of  their  pupils,  and  stimulates  them  to  further  work  in  the  field 
of  child  study.  Where  no  form  of  medical  inspection  exists,  such  tests 
by  teachers  certainly  constitute  a  useful  and  practical  first  step  toward 
securing  such  a  system.  It  is  just  as  certain  that  work  done  by  teachers 
does  not  and  cannot  render  unnecessary  the  services  of  the  trained 
medical  expert. 


CHAPTER  IX 

Administration 

For  the  purpose  of  discussing  different  phases  of  administration, 
there  may  be  distinguished  four  different  classes  of  systems  of  medical 
inspection,  all  of  them  in  force  in  different  parts  of  the  United  States. 

First :  Examinations  for  the  detection  of  physical  defects  conducted 
by  teachers.  Such  examinations  are  generally  limited  to  examinations 
of  vision  and  hearing. 

Second:  Examinations  conducted  by  physicians  for  the  detection 
of  contagious  diseases  only. 

Third:  Medical  inspections  conducted  by  physicians  for  the  de- 
tection of  contagious  diseases,  combined  with  physical  examinations 
for  the  detection  of  physical  defects. 

Fourth :  Systems  combining  the  features  of  examinations  by  teachers 
for  defects  of  vision  and  hearing,  and  examinations  by  physicians  for 
the  detection  of  contagious  diseases  and  non-contagious  physical  defects. 

Obviously,  examinations  of  the  first  sort,  that  is,  examinations 
conducted  by  teachers  for  the  detection  of  defects  of  vision  and  hearing, 
are  by  far  the  least  expensive.  Such  systems  have  been  discussed  at 
length  in  Chapter  VIII.  They  are  prescribed  by  state  law  in  Massa- 
chusetts, Vermont,  and  Connecticut;  and  have  been  or  are  being 
conducted  without  specific  legal  enactment  in  some  other  states, 
notably  New  York,  California,  and  Utah. 

The  only  expenses  incurred  in  conducting  such  examinations  are 
for  printed  material,  consisting  of  rules  of  instruction,  test  cards,  record 
blanks,  notification  cards,  etc.  Even  for  a  large  number  of  children 
the  expense  is  low.  The  Massachusetts  statute  has  the  following  sen- 
tence in  Section  6:  "  The  State  Board  of  Education  may  expend  during 
the  year  nineteen  hundred  and  six  a  sum  not  greater  than  fifteen  hundred 
dollars,  and  annually  thereafter  a  sum  not  greater  than  five  hundred 
dollars,  for  the  purpose  of  supplying  the  material  required  by  the  act." 

137 


138  Medical  Inspection  of  Schools 

In  Massachusetts  all  the  material  used  by  teachers  for  the  tests  is  sup- 
plied by  the  State  Board  of  Education  to  all  teachers.  There  are 
slightly  over  half  a  million  pupils  enrolled  in  the  public  schools  of 
Massachusetts.  At  an  annual  cost  of  five  himdred  dollars,  this  means 
that  the  tests  cost  approximately  one-tenth  of  one  cent  per  pupil.  The 
time  necessary  to  conduct  them  is  from  three  to  five  minutes  per 
pupil.  Thus  it  will  be  seen  that  both  in  time  and  in  money  the 
necessary  expenditure  is  slight. 

As  has  aheady  been  explained,  such  tests  do  not  take  the  place  of 
thorough  examinations  by  competent,  trained  experts.  That  they  are 
of  great  and  real  value,  however,  is  not  to  be  gainsaid ;  and  it  is  greatly 
to  be  doubted  if  in  the  whole  range  of  educational  endeavor  there  can 
be  discovered  another  field  where  so  great  returns  for  good  are  to  be 
secured  at  so  small  an  expenditure  of  time  and  money. 
,,^  The  second  sort  of  medical  inspection,  that  which  has  for  its  object 
to  discover  incipient  cases  of  infectious  diseases  and  by  their  removal 
from  school  to  prevent  the  disease  from  becoming  epidemic,  is  in  reality 
merely  an  extension  of  the  work  which  has  been  done  by  boards  of 
health.  It  is,  of  course,  not  expensive.  In  most  cities  the  doctors 
call  every  day  or  at  least  several  times  a  week,  and  look  over  all  the 
children  referred  to  them  by  the  teachers  as  seeming  to  be  in  ill  health 
or  who  have  returned  to  school  after  an  imexplained  absence.  Chicago 
employs  one  himdred  doctors  under  the  Board  of  Health  to  do  this  work. 
The  system  was  in  vogue  in  New  York  for  a  number  of  years.  Before 
the  passage  of  the  medical  inspection  law,  many  cities  of  Massachusetts 
had  it.     It  is  still  the  most  common  system  in  this  country. 

Under  this  plan  the  method  of  sending  for  the  doctor  varies  in 
different  towns.  Usually  in  cities  he  comes  at  stated  times  without 
being  notified,  knowing  that  he  is  sure  to  find  some  children  waiting 
for  him  to  examine.  In  some  places  the  principal  hangs  out  a  card 
as  for  the  ice  man,  and  the  doctor,  making  his  daily  roimds,  notices  it 
and  stops.  A  common  method  is  for  the  principal  or  superintendent 
to  notify  the  doctor  by  telephone. 

The  third  system  combines  with  the  inspections  for  contagious 
diseases  a  purpose  much  more  fimdamental  in  its  character  and  likely 
to  be  more  far-reaching  in  its  influence.  This  purpose  finds  expression 
in  physical  examinations  to  ascertain  whether  the  pupil  is  suffering 


Administration 


139 


from  defective  sight  or  hearing,  or  from  any  other  disability  or  defect 
tending  to  prevent  his  receiving  the  full  benefit  of  his  school  work,  or 
requiring  a  modification  of  the  school  work  in  order  to  prevent  injury 
to  the  child  or  to  secure  the  best  educational  results. 

This  system  probably  finds  its  highest  exemplification  in  the  schools 
of  New  York  City.  It  is,  of  coiu"se,  a  much  more  expensive  form  of 
medical  inspection  than  either  of  the  other  two  systems  described.  It 
requu-es  the  employment  of  skilful  physicians  for  considerable  periods 
of  time.  It  is  a  much  more  serious  matter  to  make  a  fairly  complete, 
even  if  somewhat  superficial,  physical  examination  of  a  child  than 
merely  to  decide  whether  or  not  a  child  shows  symptoms  of  some  conta- 
gious disease.  With  a  like  expenditure  of  time,  it  is  impossible  for  a 
doctor  to  look  out  for  as  large  a  number  of  children  under  this  system 
as  imder  the  preceding  one. 

Of  the  worth  of  the  complete  physical  examination  there  can  be  no 
doubt.  The  only  disadvantage  which  can  be  alleged  against  the 
system  is  that  it  often  results  in  divorcing  the  work  of  the  medical 
examiners  from  the  interests  of  the  teachers  and  the  school  authorities. 
This  is  mainly  a  difficulty  of  administration,  rather  than  inherent  in 
the  system,  and  can  largely  be  overcome. 

The  foiuth  system,  that  of  having  teachers  examine  for  vision  and 
hearing,  and  physicians  for  contagious  diseases  and  physical  defects, 
is  the  one  prescribed  by  the  Massachusetts  law.  It  is  also  in  use  in  some 
places  outside  of  that  state,  notably  in  the  city  of  Los  Angeles,  California. 
It  has  the  advantage  of  enlisting  the  interest  and  cooperation  of  the 
teachers,  while  utilizing  the  trained  knowledge  of  the  physician. 

SALARIES  OF   MEDICAL  INSPECTORS  AND  THE  NUMBER 
OF  PUPILS  PER  INSPECTOR 

The  foregoing  description  of  the  different  systems  of  medical  in- 
spection has  been  necessary  in  order  to  discuss  the  question  of  salaries, 
on  accoimt  of  the  great  variation  in  different  localities  as  to  the  work 
performed  and  the  remuneration  received.  The  following  table  gives 
the  facts  in  regard  to  the  number  of  inspectors,  salaries,  number  of 
children  per  inspector,  and  per  capita  cost  for  salaries  for  seventeen 
cities: 


140 


Medical  Inspection  of  Schools 


FACTS  IN 

REGAI 

ID  TO  I 

HEDICA] 

:  INSP] 

ECTION 

IN 

SEVENTEEN  CITIES 

City.           State. 

Average 
Attend- 
ance. 

Medical 
Inspectors. 

Children 

Per 
Inspector 

Salaries 
OF  In- 
spectors. 

Total 

OF 

Salaries. 

Per 

Capita 

Cost  for 

Salaries 

Only. 

Boston Mass. . 

.   86,839 

80 

1085 

$200 

$16,000 

$.184 

Brockton... Mass.  . 

-      7,781 

7 

Iiii 

200 

1,400 

.179 

Camden  ...N.  J.  .. 

.      9,718 

I 

9718 

2400 

2,400 

.247 

Chelsea Mass. . 

.      6,047 

3 

2015 

200 

600 

.099 

Detroit Mich.  . 

-  37.7'57^ 

27 

1398 

250 

6,75° 

.178 

Lawrence  ..Mass.  . 

-     7,530 

I 

7447 

1500 

1,500 

.201 

Montclair  ..N.  J. .. 

■     2,503 

4 

625 

305 

1,220 

.487 

Newark.    ..N.  J.  .. 

-  .38,562 

16 

2410 

400 

6,400 

.165 

New  Haven  Conn.  . 

-  18,135 

5 

3627 

240 

1,200 

.066 

New  York..  N.Y.  . 

.523,084 

166  . 

3151 
5168    ■ 

1200 
I  at  1 

199,200 

.380 

Paterson  ...N.  J.  .. 

-  15,238 

3 

1500 

2  at 

1200  ■ 

3,900 

•251 

l 

f 

I  at  1 

Seattle Wash.. 

.  16,174 

II 

1 
1470    ■ 

1200 
10  at 
600  • 

7,200 

•445 

SomervillcMass.  . 

.   11,166 

7 

1581 

200 

1,400 

.126 

Springfield.  Mass.  . 

.  10,605 

II 

964 

250 

2,750 

•259 

Woonsocket  R.  I.  . . 

.     2,862 

6 

477 

50 

300 

.104 

Worcester  .  .Mass.  . 

.  18,273 

15 

1218 

200 

3,000 

.164 

A  number  of  considerations  are  necessary  to  the  iinderstanding  of 
the  table.  In  the  first  place,  the  expense  for  salaries  of  inspectors  is 
not  the  whole  expense  for  medical  inspection.  In  all  of  the  cities  ex- 
penditures for  printing  and  incidentals  are  necessary,  and  in  Boston 
and  New  York  there  is  the  ver}'^  considerable  added  expense  for  paying 
large  corps  of  trained  nurses.  It  is  further  to  be  remembered  that  the 
inspectors  in  New  York  receive  their  salaries  at  $100  per  month  in 
return  for  their  services  as  district  physicians  of  the  Board  of  Health 
and  that  their  duties  as  school  physicians  constitute  only  a  part  of  their 
work.  Again,  in  cities  where  a  considerable  number  of  inspectors  is 
employed,  they  are  under  the  supervision  of  chief  inspectors  who  receive 
higher  salaries.  These  salaries  do  not  appear  in  the  table.  Still 
another  consideration  is  that  in  most  of  these  cities  the  doctors  conduct 


Administration  141 

examinations  for  the  detection  of  contagious  diseases  only,  while  in  a 
few  they  make  the  much  more  exacting  physical  examinations  and 
consequently  fewer  of  them.  In  short,  conditions  vary  so  that  they 
are  not  comparable  on  a  basis  of  equality  in  any  two  cities. 

Bearing  the  above  considerations  in  mind,  a  study  of  the  table  becomes 
possible.  The  number  of  children  per  inspector  varies  from  477  in 
Woonsocket,  R.  I.,  to  more  than  twenty  times  that  number,  or  9,718,  in 
Camden,  N.  J.;  but  the  Woonsocket  inspectors  receive  an  annual 
remimeration  of  $50  per  year  apiece,  while  the  inspector  in  Camden 
receives  $2,400.  These  two  cities  also  mark  the  extremes  in  the  size 
of  salary  paid.  In  the  matter  of  the  per  capita  cost  for  salaries,  how- 
ever, New  Haven,  Conn.,  stands  at  the  foot  of  the  list,  with  an  expendi- 
ture of  6.6  cents  for  each  pupil,  and  Montclair,  N.  J.,  at  the  head  with 
one  of  48.7  cents  per  pupil. 

Of  coiu-se,  m.any  cities  having  systems  of  medical  inspection  do  not 
appear  in  the  table,  and  some  of  them  represent  still  greater  extremes. 
In  many  places  the  work  is  carried  on  by  volunteer  workers  without 
remuneration.  The  towns  of  Shelburne  and  Littleton,  Alass.,  pay  their 
school  physicians  $25  per  year.  The  committee  appointed  by  the 
School  Board  of  Harrisburg,  Pa.,  to  investigate  and  report  on  medical 
inspection  reported  in  April,  1908,  that  twenty-four  cities  replied  to  their 
questions  as  to  the  per  capita  cost  of  medical  inspection.  The  answers 
ranged  from  $.00^^  to  $1.22. 

These  facts  and  considerations  lead  to  the  conclusion  that  there 
has  not  yet  been  adopted  in  this  country  any  recognized  basis  for  the 
equitable  remimeration  of  the  services  of  the  school  physician.  One 
thing  seems  certain — that  the  almost  universal  tendency  is  to  so  imder- 
pay  this  work  as  to  give  the  whole  movement  an  appearance  of  trivi- 
ality and  fail  to  attract  competent  and  experienced  men  of  the  medical 
profession.  There  can  be  no  doubt  of  the  validity  of  the  opinion 
expressed  by  Professor  Osier  in  speaking  of  the  work  of  medical  inspec- 
tion in  England:  "If  we  are  to  have  school  inspection,  let  us  have 
good  men  to  do  the  work  and  let  us  pay  them  well.  It  will  demand  a 
special  training  and  a  careful  technique."  It  is  certainly  to  be  regretted 
that  this  point  of  view  has  not  been  more  generally  taken  in  America. 

That  the  words  of  the  eminent  Oxford  professor  were  heeded  in 
his  own  covmtry  seems  evident  from  the  salaries  paid  to  the  medical 


142  Medical  Inspection  of  Schools 

inspectors  of  schools  in  England.  Almost  without  exception  the  ten- 
dency is  to  pay  much  higher  salaries  than  in  America  and  to  make 
much  more  liberal  provision  for  clerk  hire  and  for  meeting  incidental 
expenses.  Apparently  by  common  consent  the  whole  movement  has 
been  placed  upon  a  higher  plane  than  in  the  United  States.  The 
English  law  has  but  recently  been  put  into  operation,  and  the  English 
newspapers  have  contained  many  accounts  of  the  meetings  of  coimty 
covmcils  where  the  new  organizations  were  discussed  and  salaries 
decided  upon.  It  is  both  interesting  and  instructive  to  note  the  results 
of  some  of  these  meetings. 

In  Northampton  two  inspectors  have  been  appointed  at  salaries 
of  $1500  apiece  per  year.  In  North  Cumberland  County  it  is  estimated 
that  there  are  11,500  children  to  be  examined.  To  do  this  work, 
two  medical  inspectors — one  a  man  and  the  other  a  woman — have 
been  appointed.  They  receive  $1200  apiece,  besides  travelling  expenses, 
and  a  clerk  has  been  appointed  to  do  the  clerical  work.  An  amendment 
introduced  for  the  piu-pose  of  paying  the  woman  doctor  less  than  the 
man  was  defeated.  The  County  of  Guildford  has  employed  a  chief 
medical  officer  at  $3000,  to  be  increased  by  annual  increments  to  $4000, 
and  four  assistants  who  are  to  receive  $1 250  each.  Each  of  these  officials 
receives  in  addition  $200  for  travelling  expenses.  Stafford  employs  a 
senior  medical  officer  at  $1515  and  three  jimior  women  inspectors  at 
$1250,  to  be  increased  by  annual  increments  to  $1500.  These  officers 
also  receive  $2.00  for  subsistence  for  each  night  they  are  forced  to 
spend  away  from  home.  They  are  also  supplied  with  a  clerk  who 
receives  $405.  In  the  West  Riding  District  it  is  estimated  that  there 
are  50,000  children  to  be  examined.  The  total  cost  of  this  work  has 
been  calculated  at  $25,000.  Of  this  sum,  $17,500  is  to  be  devoted  to 
salaries,  $4000  to  expenses,  and  $1000  to  equipment.  Many  advertise- 
ments have  appeared  in  The  Lancet  of  young  surgeons  with  some 
experience  in  children's  hospitals  who  are  willing  to  undertake  the 
work  at  salaries  ranging  from  $1250  to  $4500  per  year. 

It  is  to  be  remarked,  too,  in  considering  these  English  salaries  that 
the  amounts  paid  represent  relatively  greater  salaries  than  would  the 
same  sums  in  America.  The  English  law  also  requires  but  three  ex- 
aminations in  the  course  of  the  school  life  of  the  child,  whereas  the 
statute  of  Massachusetts,  where  the  standard  salary  of  a  school  physician 


Administration  143 

is  $200  per  year,  requires  that  such  a  complete  physical  examination 
of  each  child  be  made  ever}'  year. 

In  view  of  the  differences  of  the  work  locally  and  the  great  variations 
of  the  conditions  under  which  medical  inspectors  work  in  different 
localities,  it  is  impossible  to  lay  down  any  rule  as  to  the  proper  number 
of  pupils  for  each  inspector.  Assignments  of  schools  to  inspectors 
should  be  governed  by  the  consideration  of  such  local  conditions  as  the 
distances  separating  schools,  the  size  of  the  schools,  the  age  of  the 
children,  and  whether  or  not  the  work  presents  special  difficulties, 
such  as,  for  instance,  foreign  race  and  nationality  of  the  children. 

Moreover,  it  is  evident  that  the  greater  the  number  of  children  for 
each  inspector,  the  less  intimate  will  be  the  knowledge  he  has  of  the 
individual  children.  WTiere  examinations  are  conducted  for  the  de- 
tection of  contagious  diseases  only  and  doctors  examine  only  those 
children  referred  to  them  by  the  teachers  as  being  suspicious  cases, 
it  is  pretty  generally  the  opinion  that  the  proper  number  is  two,  three, 
or  even  four  thousand  children  per  doctor,  depending  largely  on  the 
distances  to  be  travelled  to  reach  the  schools.  In  school  systems  where 
school  physicians  conduct  formal  physical  examinations,  besides  in- 
specting for  the  detection  of  contagious  diseases,  it  is  not  uncommon 
to  have  them  work  three  hours  each  forenoon,  from  nine  to  twelve. 
Under  these  circumstances  they  receive,  of  course,  much  higher  remuner- 
ation than  under  the  system  just  mentioned,  and  can  attend  to  fewer 
pupils.  Dr.  John  J.  Cronin,  Assistant  Chief  Medical  Inspector  of  the 
New  York  City  Board  of  Health,  is  of  the  opinion  that  under  these 
circimistances  there  should  be  one  medical  inspector  and  one  nurse 
for  each  t^^o  thousand  pupils.  WTiere  the  doctors  make  physical 
examinations,  the  fact  that  each  examination  requires  from  twelve  to 
fifteen  minutes  on  the  average  must  be  used  as  a  basis  for  deciding  on 
an  equitable  remuneration,  according  to  the  local  rates  of  remuneration. 
In  smaller  places  where  the  doctors  visit  the  schools  only  upon  the 
request  of  the  principal  or  superintendent,  it  is  sometimes  customary 
to  pay  them  at  the  local  rate  per  visit,  considering  the  whole  school  as 
one  patient. 

y  New  York  pays  its  nurses  $75  per  month  and  employs  them  for 
twelve  months  in  the  year.  Boston  pays  the  supervising  nurse  $924 
for  the  first  year,  which  is  increased  by  an  annual  increment  of  $48 


144  Medical  Inspection  of  Schools 

to  a  maximum  of  $iii6.  The  assistant  nurses  receive  $648  per  year 
and  an  annual  increase  of  $48  until  the  maximum  of  $840  is  reached. 
New  Haven  pays  its  niirse  $600  per  year. 

In  both  England  and  Germany  arrangements  are  often  made  in 
regard  to  payments  for  medical  inspection  which  might  well  be  studied 
with  a  view  to  their  introduction  in  America.  In  England  it  is  not 
uncommon  to  pay  according  to  the  work  done,  rather  than  to  decide 
on  any  fixed  amount.  Thus  physicians  in  Derbyshire  submitted  an 
estimate  to  the  County  Council  for  conducting  physical  examination 
of  pupils  at  the  rate  of  2  s.  10  d.  per  head;  in  Worcestershire  the  price 
agreed  upon  was  i  s.  8  d.  per  head.  In  the  County  of  Somerset  the 
physicians  receive  i  s.  3  d.  for  each  pupil  in  the  rural  districts  and  i  s.  in 
the  urban  districts.  In  the  North  Riding  and  Yorkshire  Districts  the 
arrangement  is  that  the  medical  ofl&cer  shall  receive  i  s.  per  child  for 
physical  examinations,  with  the  addition  of  £1  a  school  in  rural  districts. 

In  "The  Medical  Inspection  of  Schools  in  Germany"  (" Das  Schul- 
artzwesen  in  Deutschland''),  Dr.  Paul  Schubert  has  the  following  to 
say  regarding  the  salaries  of  school  physicians : 

"As  to  the  salaries  of  school  physicians  there  are  two 
methods — a  fixed  salary  and  payment  according  to  work 
done.  In  many  cities  there  is  a  combination  of  the  two 
systems,  that  is,  a  certain  addition  is  made  to  the  fixed 
salary.  For  instance,  in  Wiesbaden  the  fixed  salary  of  the 
school  physician  is  600  marks  and  a  special  remuneration 
is  made  for  the  examination  of  all  children  in  their  first, 
third,  fifth,  and  eighth  years  of  school  life.  In  Leipzig 
the  fixed  salary  is  300  to  500  marks,  according  to  the  size 
of  the  district,  and  an  additional  sum  of  200  marks  is 
paid  for  the  examination  of  pupils  entering  school.  In 
Aix-la-Chapelle  each  school  physician  receives  out  of 
the  total  appropriation  of  6000  marks  a  fixed  salary  of  500 
marks;  the  remainder  is  divided  among  the  physicians 
at  the  end  of  the  year,  according  to  the  number  of  children 
that  each  physician  has  examined." 

"  In  Mannheim  the  system  of  medical  inspection  is  upon 
an  altogether  different  basis.     There  one  school  physician 


Administration  145 

is  in  general  charge  (precluding  private  practice)  with  a 
salary  of  10,000  marks.  We  await  results  of  this  arrange- 
ment." 

A  feature  of  the  financial  administration  of  medical  inspection  which 
has  received  adequate  attention  abroad,  but  which  has  been  almost 
entirely  neglected  here,  is  that  of  furnishing  medical  inspectors  with 
adequate  clerical  assistance.  In  the  nature  of  the  case,  the  work  requires 
the  making  of  a  great  many  entries  on  individual  record  cards  or  sheets ; 
and  upon  the  thoroughness  and  system  with  which  it  is  done  depends 
to  a  large  degree  the  efficacy  of  the  work.  Recent  careful  timing  of 
work  done  by  one  of  the  most  skilful  examiners  in  the  employ  of  the 
New  York  City  Board  of  Health  shows  that  it  took  him  on  the  average 
about  twelve  minutes  to  make  each  physical  examination.  Almost 
exactly  half  of  this  time  was  employed  in  conducting  the  examination 
itself  and  the  other  half  was  spent  in  the  purely  clerical  work  of  entering 
results  on  the  sheets.  The  very  writing  of  the  names  of  the  pupils  on 
their  individual  record  cards  and  those  of  the  parents  on  notification 
postal  cards  often  consumes  a  great  deal  of  time  in  some  quarters  of 
the  city,  and  constitutes  a  class  of  work  which  ought  not  to  be  foisted 
on  to  a  trained  physician.  Here  are  some  names  taken  more  or  less 
at  random  from  the  school  registers  in  a  PoHsh  section : 

Rzemieszkievicz,  Klymezynski, 

Zdrojewski,  Wrzesimski, 

Gorzelanczyk,  Guleszecwicz. 

When  a  doctor  is  being  paid  at  the  rate  of  from  one  dollar  to  two  dollars 
per  hour,  it  is  certainly  a  most  unbusinesslike  and  inefficient  policy  to 
require  him  to  spend  half  of  his  time  doing  work  which  a  clerk  at  twelve 
or  fifteen  dollars  a  week  could  perform  equally  well.  The  doctor  in 
question  said  in  answer  to  a  query  that  he  felt  sure  he  could  examine 
twice  as  many  children  in  the  given  time  if  he  had  the  help  of  a  clerk 
and  that  he  would  find  the  work  much  more  agreeable.  This  is  a  matter 
which  demands  attention  wherever  systems  of  medical  inspection  are 
to  be  installed.  It  is  at  present  one  of  the  weak  points  of  all  American 
systems. 

It  is  very  difficult  to  gather  reliable  information  as  to  the  general 


146  Medical  Inspection  of  Schools 

expenses  of  medical  inspection  outside  of  the  matter  of  salaries  in  Ameri- 
can cities.  Apparently  in  most  places  no  careful  account  has  been  kept. 
The  expenses  for  printing,  incidentals,  etc.,  in  connection  with  medical 
inspection  have  simply  been  included  with  the  general  expenses  of  the 
board  of  health  or  board  of  education.  In  only  a  few  cases  is  informa- 
tion available.  In  Springfield,  Mass.,  the  average  attendance  of  the 
public  schools  is  10,605.  The  expenses  for  medical  inspection  for  the 
year  1907  were  as  follows: 

MEDICAL  INSPECTION  OF  SCHOOLS,  SPRINGFIELD,  MASS. 

Receipts. 
By  appropriation $2000.00 

ExpendituTes. 

Salaries  of  inspectors $1970.00 

Printing 25.15 

Postage 4.00 

Total  payments 1999.15 

To  contingent  account .85 

$2000.00 


Montclair,  N.  J.,  has  an  average  attendance  in  its  public  schools 
of  2,503.  The  following  is  an  account  of  the  expenses  for  the  medical 
inspection  for  the  school  year  ending  December  31,  1907: 


MEDICAL  INSPECTION  OF  SCHOOLS,  MONTCLAIR,  N.  J. 

Receipts. 

On  hand  Jan.  i,  1907 $1018.60 

Appropriated  by  Town  Council 1750.00 

$2768.60 

Expenditures. 
Salary  of  inspectors,  Jan.  i  to  July  i ,  1907 .  990.00 

Salary  of  inspectors,  July  i  to  Dec.  31,1907  660.00 

1650.00 

Supplies  Jan.  i  to  July  i,  1907 21.20 

Supplies  July  i  to  Dec.  31,  1907 47-93  69.13 

$1719-13 
Balance  on  hand  Jan.  i,  1908,  to  carry  till  July  i,  1908 1049.47 

$2768.60 


Administration  147 

In  decided  contrast  to  these  meagre  appropriations,  and  showing 
that  the  English  policy  is  as  much  more  adequate  than  the  American 
in  the  matter  of  appropriations  for  incidentals  as  in  that  of  salaries, 
is  the  estimate  of  cost  of  medical  inspection  at  East  Sussex,  England. 
The  district  contains  176  schools  and  approximately  26,000  pupils, 
of  whom  21  per  cent.,  or  5,460,  are  to  be  examined  the  first  year.  The 
following  is  a  financial  estimate  of  the  subcommittee  of  the  East  Sussex 
Education  Committee: 


MEDICAL  INSPECTION  OF  SCHOOLS,  EAST  SUSSEX, 
ENGLAND 

Salaries  and  travelling  expenses $3547.80 

176  weighing  machines  at  $6.06  each 1066.56 

176  height  measuring  standards  at  84  cents  each 147-84 

360  copies  Snellen's  test  at  $2.40  per  doz 72.00 

176  screens  at  $2.40  each 422.40 

15,000  cards  at  $4.86  per  thousand 73-9° 

240  card  cabinets 437.40 

15,000  notices  to  parents  at  $2.43  per  thousand 36.45 

Sundries 607.50 


Total  for  appliances  and  incidentals $2864.05 

Total  cost  for  first  year $641 1.85 

There  are  many  other  minor  questions  of  administration  which 
present  themselves  for  discussion.  Some  of  these  are:  Is  it  better 
to  have  medical  inspectors  devote  their  entire  time  to  the  work,  or  is  it 
preferable  that  they  give  only  part  of  their  time  and  have  outside  prac- 
tice? Should  the  doctor  be  allowed  to  prescribe  for  children?  What 
should  be  done  in  the  case  of  parents  too  poor  or  too  indifferent  to  take 
measures  recommended  by  the  physicians  ?  If,  for  instance,  the  child 
has  defective  vision  and  glasses  are  needed,  who  is  to  furnish  them 
if  the  parents  fail  to  do  so  ? 

It  is  difficult  to  answer  these  questions  because  in  many,  if  not 
most,  cases  the  answer  depends  on  local  conditions.  It  is  the  general 
opinion  of  the  best  authorities  that  medical  inspectors  should  not  devote 
their  w'hole  time  to  the  school  work.  The  work  is  exceedingly  monoto- 
nous, and  if  the  doctor  is  prohibited  from  having  an  outside  practice 


148  Medical  Inspection  of  Schools 

opportunities  for  increasing  his  skill  and  enlarging  his  experience  are 
to  a  great  extent  cut  off. 

To  the  question  as  to  whether  a  doctor  should  prescribe  for  children, 
the  answer  must  be  made  that  under  no  conditions  should  he  lay  himself 
open  to  the  charge  that  he  is  using  his  official  position  for  the  purpose 
of  enlarging  his  private  practice.  This  is  the  basis  for  the  almost 
invariable  rule  that  except  in  cases  of  emergency  the  school  doctor 
shall  not  prescribe. 

It  has  been  suggested  that  in  cities  of  small  size  and  in  towns  there 
should  be  employed  one  man,  a  physician,  thoroughly  trained  in  the 
science  of  modern  preventive  medicine,  who  should  fill  the  offices  of 
school  medical  inspector,  director  of  physical  training  in  the  public 
schools,  and  director  of  physical  training  in  the  playgrounds  during 
the  summer  months.  By  such  an  arrangement  a  salary  could  be  paid 
that  would  attract  the  best  men,  without  undue  burden  on  the  tax- 
payers, even  in  comparatively  small  places. 

The  problem  of  furnishing  free  eyeglasses  for  indigent  pupils  has 
been  widely  discussed.  As  far  back  as  1901  the  city  of  Cleveland 
gave  away  400  pairs  to  pupils  needing  them  and  whose  parents  claimed 
to  be  unable  to  meet  the  necessary  expense.  In  a  number  of  cities  first 
class  opticians  have  made  offers  to  furnish  glasses  at  a  uniform  price 
of  $1  a  pair  to  school  children.     A  case  in  point  is  Lowell,  Mass. 

In  Philadelphia  there  is  a  city  ophthalmologist  who  prescribes  for 
children  found  to  have  defective  vision,  and  then  glasses  are  furnished 
through  his  office  at  the  cost  price  of  eighty-five  cents  a  pair. 

In  most  places  where  the  matter  has  been  carefully  studied  it  is 
found  that  careful  follow-up  work  on  the  part  of  the  school  authorities 
will  result  in  nearly  all  of  the  cases  being  taken  care  of  by  the  parents 
of  the  children,  and  in  the  cases  of  families  genuinely  unable  to  meet 
the  expense  it  has  always  been  possible  to  arrange  with  charitable 
organizations  to  furnish  the  glasses.  The  percentage  of  cases  where 
this  has  been  found  necessary  or  desirable  is  exceedingly  small. 

In  summing  up  the  problems  of  administration  which  relate  to  expense 
it  can  only  be  said  that  in  this,  as  in  all  other  branches  of  organized 
endeavor,  cost  varies  with  the  extent  and  kind  of  work  done.  Examina- 
tions by  teachers  for  the  discovery  of  defects  of  vision  and  hearing 
involve  only  the  added  expense  of  the  simple  printed  material  required. 


Administration 


149 


Inspection  by  physicians  for  the  detection  of  contagious  diseases  is 
inexpensive  and  of  great  value  in  its  results. 

Systems  of  medical  inspection  which  include  careful  physical  ex- 
aminations of  all  children  cost  the  most  and  are  by  far  the  most  valuable. 
From  a  social  and  economic  viewpoint  they  are  by  far  the  cheapest 
in  the  better  sense  of  the  word,  as  they  are  the  most  far-reaching  both 
in  their  immediate  and  in  their  indirect  results. 

If,  however,  a  system  of  medical  inspection  is  to  be  eflScient  and 
effective  for  any  considerable  length  of  time,  it  is  clear  that  adequate 
salaries  must  be  paid  to  those  in  charge  of  the  work. 

Efficient  work  can  not  long  be  expected  from  volunteers,  and  perhaps 
even  less  will  it  be  given  by  physicians  who  receive  a  bare  pittance 
in  retiim  for  their  time  and  skill.  Neither  can  it  be  expected  that 
first-class  men  will  long  be  content  to  spend  most  of  their  time  in  doing 
the  piu-ely  clerical  work  of  filling  out  blanks  in  duplicate  and  triplicate. 

Permanent  efficiency  will  require  skilled  workers,  careful  adminis- 
tration and  adequate  remuneration. 


CHAPTER  X 

Controlling  Authorities 

Under  American  systems  of  municipal  government,  the  question 
as  to  whether  medical  inspection  of  schools  is  a  proper  function  of  the 
board  of  education  or  the  board  of  health  is  bound  to  arise  as  soon  as  the 
organization  of  such  a  system  is  contemplated.  Both  sides  of  the 
question  are  certain  to  be  warmly  argued. 

On  the  side  of  the  board  of  health  is  the  argument  that  the  machinery 
of  government  already  existing  for  the  conservation  of  the  health  of 
the  community  may  properly  be  extended  to  include  new  activities, 
and  that  another  branch  of  the  government  should  not  duplicate  social 
machinery  already  existing.  It  is  further  argued  that  an  important 
feature  of  the  medical  inspection  of  schools  is  the  detection  and  segrega- 
tion of  cases  of  contagious  disease.  This  is  a  protective  measure  re- 
lating to  the  safety  of  the  whole  community,  and  as  such  should  remain 
a  function  of  the  board  of  health. 

On  the  side  of  the  argument  for  keeping  the  work  in  the  hands  of 
the  board  of  education  it  is  claimed  that  the  whole  work,  to  be  effective, 
must  be  so  closely  related  to  school  work  and  school  records  that  friction 
inevitably  results  when  those  in  charge  are  in  the  employ  of  an  outside 
body,  neither  responsible  to  nor  perhaps  in  sympathy  with  those  having 
schools  in  charge.     This  results  in  a  loss  of  efficiency. 

The  further  claim  is  made,  and  substantiated  by  referring  to  records 
of  work  done  in  many  cities,  that  the  exclusion  of  cases  of  contagious 
disease  is  after  all  a  comparatively  small  part  of  the  work  of  medical 
inspection,  even  where  the  work  is  confined  to  the  examination  for  the 
detection  of  cases  of  contagious  disease  and  physical  examinations 
are  not  made.  Thus  in  Haverhill,  Mass.,  in  1907  the  total  exclusions 
amounted  to  222  in  a  school  membership  of  5230,  or  about  4  per  cent. 
In  Newark,  N.  J.,  in  the  same  year  the  exclusions  were  1579  in  a  school 

15° 


Controlling  Authorities  151 

membership  of  38,562,  or  again  4  per  cent.  In  the  State  of  Massa- 
chusetts in  1907,  towns  and  cities  having  an  average  attendance  of 
342,000  reported  something  more  than  15,000  exclusions  during  the  year. 
Again  the  percentage  is  4.  In  all  of  these  cases  a  large  proportion — in 
fact  nearly  half  of  the  exclusions — are  on  account  of  one  cause,  pedicu- 
losis (lice).  In  cities  where  school  nurses  are  employed,  these  cases 
are  not  excluded  and  thus  the  number  of  exclusions  is  greatly  cut  down. 
In  New  York  in  1906  the  exclusions  amounted  to  11,101  among  a 
school  membership  of  505,000,  or  only  2  per  cent. 

A  good  idea  of  the  feeling  of  those  in  charge  of  the  work  in  localities 
where  the  question  as  to  administration  has  been  raised  may  be  gained 
from  reading  some  extracts,  mostly  taken  from  official  reports,  made 
by  executive  officers. 

In  his  report  for  1907,  Dr.  William  H.  Maxwell,  City  Superinten- 
dent of  Schools  of  New  York,  says: 

"Dual  responsibility  in  the  school — that  of  the  Board 
of  Education  and  that  of  the  Department  of  Health — 
always  has  resulted  and  always  will  result  in  confusion 
and  inefficiency  in  the  work  effected.  It  is  owing  to  this 
dual  responsibility  that  the  large  annual  appropriation 
made  by  the  city  for  the  physical  examination  of  school 
children  is  to  a  great  degree  wasted.  Efficient  service 
will  be  obtained  only  when  the  Board  of  Education  is 
made  solely  responsible  for  all  the  work  that  goes  on  in 
the  schools. 

"The  physicians  employed  by  the  Board  of  Health  do 
not  perform  any  of  the  functions  which  it  is  highly  advisa- 
ble should  be  performed  by  a  truly  educational  department 
of  hygiene,  such  as  studying  hygienic  conditions  in  the 
schools  and  advising  teachers  regarding  the  pedagogical 
treatment  of  children  in  cases  of  fatigue  and  nervousness. 

"The  nurses  employed  by  the  Department  of  Health 
have  done  good  work  in  visiting  the  homes  of  sick  children, 
in  giving  advice  and  assistance  to  mothers,  and  in  looking 
after  slight  ailments  in  the  school.  The  fact,  however,  that 
they  are  under  the  control  of  an  outside  organization  is  a 


152  Medical  Inspection  of  Schools 

constant  hindrance  to  their  work.  It  is  another  instance 
of  the  evil  effects  which  arise  from  dual  control  or  divided 
responsibility.  I  risk  nothing  in  saying  that  the  school 
nurses  would  do  much  more  and  better  work  if  they  were 
made  responsible  to  the  educational  authorities." 

Dr.  Thomas  F.  Harrington,  of  the  Department  of  Hygiene,  Boston, 
says  in  speaking  of  the  system  of  medical  inspection  by  physicians 
in  the  employ  of  the  Department  of  Health: 

"  The  greatest  criticism  against  this  system  of  inspection 
is  that  it  lacks  uniformity;  that  it  excludes  pupils,  and 
does  not  provide  any  means  of  'follow  up'  nor  any  guar- 
antee that  the  child  will  receive  medical  care;  that  the 
duties  of  the  inspector  as  an  agent  of  the  Board  of  Health 
bring  him  in  contact  with  much  contagion  in  the  homes; 
and  finally  that  the  dual  duties  and  divided  responsibility 
are  not  conducive  to  the  best  in  the  health  and  efficiency 
of  school  children." 

In  speaking  of  the  work  of  the  school  nurses,  he  says: 

"  It  does  not  seem  possible  to  conceive  a  more  satisfac- 
tory arrangement,  nor  a  more  effective  piece  of  school 
machinery  than  niirses  under  school  supervision.  With 
a  corps  of  medical  inspectors  under  this  same  supervision, 
who  would  conduct  a  daily  clinic  in  their  respective  school 
districts,  there  are  no  problems  connected  with  the  health 
and  efficiency  of  school  children  which  could  not  be  quietly, 
rationally,  economically  and  effectually  solved.  Until 
such  an  organization  is  perfected  in  part  or  in  whole, 
little  progress  can  result  from  the  efforts  to  promote  the 
health  and  efficiency  of  our  school  children." 

The  Superintendent  of  Schools  of  Boston  in  his  twenty-seventh 
annual  report,  July,  1907,  says  in  regard  to  the  Massachusetts  law 
making  medical  inspection  compulsory: 


Controlling  Authorities  153 

"In  this  connection  it  should  be  stated  that  while  the 
school  physicians  were  concerned  solely  with  contagious 
diseases,  they  were  properly  to  be  controlled  by  the  Board 
of  Health.  Under  the  new  law,  the  work  of  examining  into 
any  defect  that  interferes  with  the  progress  of  the  children 
in  school  is  not  in  the  main  a  question  of  public  health. 
It  is  rather  an  educational  question  and  is  so  directly 
allied  to  the  work  of  the  Department  of  Physical  Training 
that  the  school  physicians  should  be  appointed  by  the 
school  board  and  become  a  part  of  this  department. 
The  highest  efficiency  will  be  impossible  until  this  action 
is  taken." 

The  Superintendent  of  Schools  of  Cleveland  says  in  his  report 
for  1907,  after  making  an  able  plea  for  the  establishment  in  the  schools 
of  the  city  of  a  system  of  medical  supervision : 

"While  it  has  been  suggested  that  the  kind  of  service 
here  treated  should  be  performed  by  the  Board  of  Health, 
it  is  the  belief  that  medical  supervision  is  peculiarly  a 
function  of  the  Department  of  Physical  Training  and 
School  Hygiene,  and  that  the  Board  of  Health's  relation 
to  the  schools  should  relate  to  the  matter  of  communicable 
disease." 

In  his  report  for  1907,  the  Superintendent  of  Schools  of  Newark, 
N.  J.,  says  that  the  medical  inspection  as  conducted  by  the  Board  of 
Health  has  been  satisfactory,  but  adds  that  the  only  objection  that  can 
be  raised  against  it  relates  to  the  executive  control  of  the  staff  of  medical 
inspectors.     He  says: 

"By  additions  to  the  staff,  the  number  of  medical  in- 
spectors now  employed  in  the  schools  is  16.  The  direction 
and  control  of  this  large  number  requires  some  one  who 
can  give  more  time  to  it  than  is  possible  for  the  bvisy  and 
overworked,  but  exceedingly  efficient,  health  officer. 
It  seems  hardly  fair  to  impose  upon  him  in  addition  to 


154  Medical  Inspection  of  Schools 

his  other  duties  the  duty  of  overseeing  daily  the  work  of 
sixteen  medical  inspectors. 

Dr.  Fred  S.  Shepherd,  Superintendent  of  Schools  of  Asbury  Park, 
N.  J.,  says: 

"Again,  if  the  system  is  to  work  harmoniously,  the 
medical  inspector  should  work  under  the  direction  of  the 
Superintendent  of  Schools,  as  do  the  teachers.  If  the 
medical  inspector  should  regard  himself  as  not  called  upon 
to  accept  any  suggestions  whatsoever  from  the  school 
officers  of  administration,  such  as  superintendents  or 
school  principals,  it  is  plain  that  friction  might  arise.  In 
this  connection  we  should  not  overlook  the  fact  that 
medical  inspectors  are  human  and  have  a  few  of  the 
faults  common  to  humanity.  It  is  possible  for  them,  as 
it  is  for  teachers  and  others  higher  in  authority,  to  slight 
their  duties  or  to  perform  them  in  an  inefficient  and  un- 
satisfactory manner.  School  boards  are  not  able  to  pass 
judgment  upon  these  inner  workings  of  the  system,  and 
somebody  should  have  the  responsibility  for  holding  even 
medical  inspectors,  if  necessary,  to  the  letter  if  not  to  the 
spirit  of  their  obligations." 

It  is  to  be  noted  that  Superintendent  Shepherd  is  speaking,  not  from 
the  point  of  view  of  the  theorist,  but  from  that  of  one  experienced  with 
the  workings  of  a  school  system,  having  a  successful  system  of  medical 
inspection  under  physicians  appointed  by  the  Board  of  Education.  In 
telling  of  the  workings  of  this  system  in  actual  practice,  Dr.  Shepherd 
goes  on  to  say : 

"It  has  been  suggested  in  some  quarters  that  medical 
inspection  of  school  children  should  be  one  of  the  functions 
of  the  local  board  of  health,  in  order  to  prevent  clashing 
of  authority.  As  boards  of  health  are  organized  in  our 
own  State,  however,  I  can  see  no  likelihood  of  such  cross 
purposes.  I  presume  it  does  devolve  upon  local  boards 
of  health  to  inspect  for  sanitary  purposes  all  pubhc  build- 


Controlling  Authorities  155 

ings,  including  the  public  schools.  This,  I  judge,  is  also, 
or  should  be,  one  of  the  duties  of  the  medical  inspector. 
To  have  the  public  schools  inspected  intelligently  by  two 
such  departments  seems  to  me  a  good  thing.  WTiat  one 
might  overlook,  the  other  might  see.  Aside  from  this  ap- 
parent overlapping  of  jurisdiction,  I  see  little  opportunity 
for  any  clashing  of  interest.  On  the  contrary,  it  is  possi- 
ble for  the  very  closest  relations  to  be  established 
between  boards  of  health  and  the  school  medical  au- 
thorities. How  it  might  be  in  other  cities  of  the  State,  I 
am  not  aware;  but  in  the  city  of  Asbury  Park  every  case 
of  contagious  or  infectious  disease  is  reported  immediately 
by  the  Board  of  Health  to  the  school  authorities,  and  vice 
versa." 

That  the  fears  expressed  by  Dr.  Shepherd  are  not  imaginary  is 
shown  by  experience  in  cities  where  the  dual  system  of  control  is  in 
practice. 

Such  an  example  comes  to  light  in  the  city  of  Lawrence,  Mass. 
There  medical  inspection  is,  of  course,  conducted  under  the  provisions 
of  the  State  statute,  which  provides  for  the  appointing  of  school  physi- 
cians by  either  the  school  committee  or  the  board  of  health.  In  Lawrence 
the  threatened  conflict  came  to  a  head  in  August,  1907,  when  the  Board 
of  Health  appointed  five  physicians  to  inspect  both  public  and  private 
schools.  By  an  order  of  the  School  Committee  the  principals  and 
teachers  were  forbidden  to  extend  ofl&cial  recognition  to  any  but  Dr. 
Bannon,  who  was  appointed  by  the  School  Committee  in  August,  1906, 
for  a  term  of  three  years.  This  continues  and  the  schools  are  under  a 
double  inspection,  with  much  consequent  unavoidable  friction. 

One  of  the  strongest  arguments  in  favor  of  medical  inspection  under 
the  authority  of  boards  of  education  is  that  the  efl&ciency  of  the  work 
demands  that  there  shall  be  the  closest  cooperation  between  the  medical 
and  the  educational  authorities.  If  the  results  of  the  work  are  to  be 
profitable,  if  diligent  effort  is  to  be  made  to  correct  the  defects  foimd, 
if  the  physical  conditions  brought  to  view  are  to  be  used  for  the  guidance 
of  the  teacher  in  the  class-room,  then  certainly  such  intimate  relation- 
ships are  essential. 


156  Medical  Inspection  of  Schools 

It  has  been  claimed  that  where  the  work  is  done  by  the  board  of 
health  this  is  difficult  or  impossible.  Certainly  an  examination  of  the 
annual  reports  of  some  of  the  superintendents  of  cities  where  the  medical 
inspection  is  conducted  by  the  board  of  health  would  seem  to  indicate 
that  the  educational  authorities  know  little  of  the  work  that  is  being 
done,  and  so  regard  it  as  of  slight  importance  as  a  guide  in  the  work  of 
the  class.  Examples  of  such  an  attitude  as  this  are  found  in  reports 
of  the  Superintendents  of  Schools  of  Haverhill  and  Springfield,  Mass., 
for  1907.  The  Superintendent  of  Schools  of  Haverhill,  Mass.,  disposes 
in  his  report  of  the  work  of  medical  inspection  with  the  following  brief 
remarks : 

"The  school  physicians  have  continued  their  work  on 
the  same  basis  as  last  year,  under  appointment  from  the 
Board  of  Health.  I  am  permitted  to  make  the  following 
summary  of  such  portions  of  their  work  as  admit  of  classi- 
fication. A  large  proportion,  perhaps  the  largest  portion 
of  their  work,  is  not  such  as  can  be  shown  in  the  form  of 
statistics." 

Then  follows  a  brief  list  of  the  diseases  noted  by  the  school  physicians 
and  of  the  statistics  concerning  vaccination.  No  details  are  given, 
nor  is  there  any  mention  made  even  of  the  number  of  pupils  examined. 
The  report  is  confined  to  some  ten  lines.  Such  comment  certainly 
does  not  seem  to  indicate  intimate  knowledge  of  the  work  being  done 
or  any  intimate  relationship  between  the  work  of  the  school  physicians 
and  that  of  the  educational  authorities. 

A  similar  condition  seems  to  be  revealed  in  Springfield,  Mass., 
where  the  sole  comment  of  the  School  Board  on  the  work  of  the  physi- 
cians appointed  by  the  Board  of  Health  is,  "So  far  as  we  can  learn, 
the  inspectors  are  fulfilling  their  requirements  and  parents  generally 
follow  the  advice  given." 

In  Massachusetts  medical  inspectors  are  appointed  in  some  of 
the  cities  by  the  boards  of  health  and  in  others  by  the  school  committees. 
After  watching  the  operation  of  the  two  systems  for  more  than  a  year 
imder  the  State  law,  Secretary  George  H.  Martin  of  the  State  Board  of 
Education  writes: 


Controlling  Authorities  igy 

"The  movement  now  in  progress,  which  has  reached 
different  stages  in  different  countries,  seems  to  be  shap- 
ing itself  so  as  to  include  as  necessary  features  the  follow- 
ing elements : 

"(i)  Physicians.  A  sufficient  number  of  trained 
physicians  to  carry  on  the  necessary  examinations  and 
exercise  the  needed  oversight  of  all  the  children  in  the 
public  and  private  schools,  these  physicians  to  act  under  the 
direction  of  the  local  educational  authority,  but  in  coopera- 
tion with  local  health  authorities.  In  the  larger  cities  the 
physicians  should  act  under  the  immediate  direction  of  a 
chief  medical  officer,  who  should  be  a  permanent  member 
of  the  educational  staff." 

In  Chapter  I  we  have  already  traced  the  two  sources  of  the  move- 
ment that  is  leading  to  the  medical  care  of  school  children;  one  develop- 
ing from  the  standpoint  of  existing  and  recognized  functions  of  the 
Department  of  Health,  and  the  other  from  a  less  well  defined  or  con- 
scious relation  of  departments  of  education  to  the  welfare  of  school 
children.  The  relation  between  these  two  functions  is  not  an  easily 
defined  one.  The  fact  that  from  a  number  of  cities  the  percentage 
of  cases  needing  exclusion  is  not  over  4  per  cent.,  while  the  number  of 
children  needing  care  with  reference  to  defects,  exercise,  suitable  seats 
and  desks,  type,  paper,  suitable  hours  of  study,  and  the  like,  include  all 
the  children,  shows  that  one  is  specific  and  hmited,  the  other  general 
and  almost  unlimited  in  its  scope. 

It  is  natural  that  those  who  have  approached  the  problem  from  the 
standpoint  of  contagious  disease  or  pathology  are  prone  to  regard  the 
whole  work  as  belonging  as  a  natural  function  to  the  department  of 
health.  It  is  equally  natural  that  those  who  are  accustomed  to  look 
at  growth  and  development  as  the  ultimate  object  should  fail  to  recognize 
the  fundamental  obligation  supported  by  legal  powers  possessed  by 
the  boards  of  health  with  reference  to  community  protection.  This 
legal  power  and  obligation  cannot  easily  be  transferred  to  any  other 
city  department,  and  should  not  be,  even  if  it  could. 

In  summing  up,  then,  we  may  conclude  as  a  result  of  the  evidence 
presented : 


158  Medical  Inspection  of  Schools 

I.  The  detection  of  contagious  diseases  in  the  schools, 
involving  daily  visits  and  the  power  of  the  law,  is  in  the 
nature  of  an  extension  of  the  powers  heretofore  exercised 
by  boards  of  health;  and  where  medical  inspection  is  to 
include  nothing  more  than  this  work,  systems  may  well  be 
administered  by  boards  of  health,  if  care  be  taken  to 
establish  and  maintain  sufficiently  close  and  friendly 
relations  with  the  school  officials. 

II.  Those  activities  which  have  to  do  with  the  child's 
physical  condition  as  related  to  his  school  work — seating, 
exercise,  hours  of  home  study — that  is  to  say  all  functions 
of  the  medical  inspection  of  schools  except  those  pertaining 
to  contagious  diseases — are  in  the  nature  of  the  case  an 
integral  part  of  school  interests  and  must  not  be  divorced 
from  them.  Moreover,  the  records  of  the  examinations 
of  school  children  for  physical  defects  likely  to  interfere 
with  proper  growth  and  education  must,  if  they  are  to  serve 
their  end,  follow  the  child  from  grade  to  grade  and  from 
school  to  school,  and  each  case  must  be  followed  up 
constantly ;  that  is,  they  are  an  important  part  of  the  school 
records  and  must  be  so  made  and  administered. 

In  brief: 

(a)  Medical  inspection  for  the  detection  of 
contagious  diseases  may  weU  be  a  function  of  the 
board  of  health. 

(b)  Physical  examinations  for  the  detection  of 
non-contagious  defects  should  be  conducted  by  the 
educational  authorities,  or  at  least  with  their  full 
cooperation,  because  they  are  made  for  educational 
purposes. 

(c)  The  records  of  physical  examinations  must 
be  constantly  and  intimately  connected  with  school 
records  and  activities. 

(d)  They  do  not  need  to  be  connected  with  other 
work  of  the  board  of  health. 


CHAPTER  XI 

Legal  Aspects  of  Medical  Inspection 

On  Friday,  April  17,  1908,  Mr.  Almuth  C.  Vandiver,  counsel  for 
the  Medical  Society  of  the  County  of  New  York,  read  a  paper  on  "  Statu- 
tory Enactments  relating  to  the  Medical  and  Sanitary  Inspection  of 
Schools"  before  the  Second  Congress  of  the  American  School  Hygiene 
Association,  then  in  session  at  Atlantic  City.  Most  of  the  facts  pre- 
sented in  the  following  chapter  have  been  through  the  courtesy  of  Mr. 
Vandiver  taken  from  his  paper. 

There  are  few  legislative  enactments  under  which  the  views  and 
beHefs,  and  results  of  experience,  of  educators  and  physicians  have  been 
crystaUized  in  Europe  and  America  in  the  field  of  medical  inspection  of 
schools.  There  are  but  two  important  statutes.  The  English  statute, 
which  became  a  law  on  January  i,  igo8,  and  that  of  the  State  of 
Massachusetts.  This  commonwealth,  always  foremost  in  pioneer  and 
progressive  legislation,  placed  upon  its  statute  books  in  1906  a  manda- 
tory medical  inspection  law  far  more  comprehensive  in  its  provisions 
than  the  English  law. 

The  English  law,  known  legally  as  "  Section  13  of  the  Administrative 
Provisions  of  the  Education  Act  of  1907,"  in  its  entirety  is  as  follows: 

13.  (i)  The  powers  and  duties  of  a  local  education 
authority  under  Part  III  of  the  Education  Act,  1902, 
shall  include:  (a)  Power  to  provide  for  children  attend- 
ing public  elementary  schools,  vacation  schools,  vacation 
classes,  play  centers,  etc.  (b)  The  duty  to  provide  for  the 
medical  inspection  of  children  immediately  before  or  at 
the  time  of  or  as  soon  as  possible  after  their  admission  to  a 
public  elementary  school,  and  on  such  other  occasions 
as  the  Board  of  Education  direct,  and  the  power  to  make 
such  arrangements  as  may  be  sanctioned  by  the  Board  of 

159 


i6o  Medical  Inspection  of  Schools 

Education  for  attending  to  the  health  and  physical  condi- 
tion of  the  children  educated  in  public  elementary  schools: 
Provided,  that  in  any  exercise  of  powers  under  this  section 
the  local  education  authority  may  encourage  and  assist 
the  establishment  or  continuance  of  voluntary  agencies, 
and  associate  with  itself  representatives  of  voluntary 
associations  for  the  purpose. 

(2)     This  section  shall  come  into  operation  on  the 
first  day  of  January,  nineteen  hundred  and  eight. 

The  English  lawmakers  are  not  quite  so  verbose  and  prolix  in  statute 
drafting  as  are  their  American  contemporaries,  and  the  interpretation 
and  construction  of  this  short  act  was  comprehensively  treated  by  the 
Board  of  Education  in  a  memorandum  issued  on  November  22,  1907, 
before  the  act  became  effective,  for  the  guidance  of  the  administrative 
officers  charged  with  the  execution  of  the  statute. 

This  course  differs  somewhat  from  the  American  system.  In  the 
United  States  the  construction  and  interpretation  of  statutes  is  left 
finally  to  the  courts.  This  procedure  is  a  lengthy  and  involved  practice. 
In  view  of  the  fact  that  the  memorandum  referred  to  has  the  practical 
effect  of  a  parliamentary  enactment  in  the  execution  of  the  law,  it  may 
be  well  to  quote  from  it  somewhat  extensively. 

It  will  be  observed  that  the  burden  of  executing  the  provisions  of 
the  statute  is  specifically  laid  upon  the  education  authorities.  This  is 
a  distinct  departure  from  the  established  course  heretofore  pursued 
in  matters  relating  to  the  pubUc  health. 

In  the  view,  however,  of  the  London  Board  of  Education  the  present 
act  is  not  intended  to  supersede  the  powers  which  have  long  been 
exercised  by  sanitary  authorities  under  various  public  health  acts, 
but  is  meant  to  serve  rather  as  an  amplification  and  a  natural  develop- 
ment of  previous  legislation. 

In  order  that  friction  between  the  education  and  health  authorities 
may  be  avoided,  if  possible,  the  Board  of  Education  in  this  memorandum 
advises  a  thorough  and  friendly  cooperation  with  such  authorities  in 
the  administration  of  the  law. 

The  second  most  noticeable  feature  about  the  act  is  that  it  makes 
medical  inspection  compulsory.     Theretofore  medical  inspection  had 


Legal  Aspects  of  Medical  Inspection  i6i 

been  more  or  less  in  vogue  in  various  localities  under  the  supervision 
of  the  education  authorities,  sometimes  in  conjunction  with  the  health 
authorities.  The  central  authority  for  the  execution  of  the  law  is  the 
Board  of  Education.  The  board's  instruments  are  the  local  education 
authorities.  In  country  areas  this  authority  is  the  county  council. 
It  is  suggested  in  the  memorandum  that  the  county  council  confer 
with  and  cooperate  with  the  county  medical  officer.  It  is  also  suggested 
that  the  county  medical  officer  have  an  assistant  appointed  by  the  county 
council,  whose  duty  shall  be  the  inspection  provided  for  by  the  statute. 

In  county  boroughs  the  town  council,  which  is  at  the  same  time 
both  the  local  authority  for  public  health,  and  also  the  local  education 
authority,  is  counselled  to  instruct  their  medical  officer  of  health  to 
advise  the  education  committee.  Where  no  medical  officer  has  been 
appointed,  it  is  suggested  that  his  appointment  be  made  by  the  educa- 
tion authorities.  WTiere  there  is  already  a  school  medical  officer,  it  is 
suggested  that  his  appointment  remain  undisturbed. 

Although  there  is  no  provision  for  school  nurses  in  the  act,  the  Board 
of  Education  advised  that  wherever  practicable  such  nurses  be  employed. 

The  Board  decided  that  not  less  than  three  inspections  during  the 
school  life  of  a  child  will  be  necessary  to  secure  the  results  desired. 
In  certain  areas,  the  Board  may  from  time  to  time  require  inspection  at 
shorter  intervals  and  of  a  more  searching  character. 

The  inspection  of  the  sanitation  of  school  buildings,  the  prevention 
of  the  spread  of  contagious  diseases,  and  the  supervision  of  the  personal 
and  home  life  of  the  child  are  also  suggested. 

Finally,  it  should  be  observed  that  there  is  in  the  act  no  section 
whatever  providing  that  parents  of  school  children,  found  diseased  or 
defective  after  such  inspection,  shall  provide  proper  medical  attention 
at  the  hands  of  their  own  physician  or  of  the  hospital  authorities. 

"Every  authority  which  has  so  far  undertaken  medical  inspection," 
says  Dr.  Hackworth  Stuart,  commenting  upon  the  new  law,  "has  ex- 
perienced great  difficulty  in  overcoming  parental  indifference  and 
neglect  in  very  many  defective  cases.  In  some  cases  it  is  at  present 
impossible  to  persuade  the  parents  to  act  on  the  notification  made  after 
the  visits  of  inspection.  Legal  proceedings  against  the  parents  for 
neglect  would  not  prove  a  very  helpful  custom  for  general  adoption." 

Dr.  Stuart  suggests  that  inspection  would  become  more  fruitful  in 


i62  Medical  Inspection  of  Schools 

its  results  if  the  education  authorities  were  empowered  to  secure  treat- 
ment of  cases  where  recommendations  of  the  inspectors  are  repeatedly- 
neglected  and  to  recover  the  costs  from  the  parents. 

In  this  view  it  is  difficult  to  coincide  so  far  as  the  United  States  are 
concerned. 

In  this  country  a  penal  provision  seems  essential  for  the  proper 
execution  of  any  law  imposing  a  duty  upon  the  people  or  any  part  of 
them. 

Prior  to  the  adoption  of  the  English  statute,  the  education  authorities 
in  various  localities  carried  on  a  system  of  notification  to  parents  of 
defects  found  to  exist  in  their  children  by  school  medical  inspectors. 
In  these  notifications,  the  parents  were  advised  to  secure  medical  atten- 
tion without  delay,  and  explanations  for  the  necessity  of  such  action 
were  included,  but  there  was  no  legal  authority  existent  to  compel  the 
parents  to  secure  such  medical  attention  if  the  same  was  neglected. 

It  was  found  by  the  school  authorities  in  Hanley  that  the  segregation 
of  defective  pupils  during  school  hours  and  during  play-time  had  a  more 
satisfactory  effect  upon  the  parents  than  any  other  method  adopted. 

Let  us  now  consider  for  a  comparison  with  the  English  statute  the 
only  legislative  enactment  existing  in  the  United  States  making  medical 
inspection  mandatory.  As  it  was  the  initial  legislative  effort  in  America 
along  this  line  it  seems  worth  while  to  quote  it  in  extenso.  Legally  it  is 
known  as  Chapter  502  of  the  Acts  of  1906,  and  became  a  law  of  the 
State  of  Massachusetts  on  the  ist  day  of  September,  1906.     It  provides: 

Section  i.  The  school  committee  of  every  city  and 
town  in  the  Commonwealth  shall  appoint  one  or  more 
school  physicians,  shall  assign  one  to  each  public  school 
within  its  city  or  town,  and  shall  provide  them  with  all 
proper  facilities  for  the  performance  of  their  duties  as 
prescribed  in  this  act:  provided,  however,  that  in  cities 
wherein  the  board  of  health  is  already  maintaining  or 
shall  hereafter  maintain  substantially  such  medical  in- 
spection as  this  act  requires,  the  board  of  health  shall 
appoint  and  assign  the  school  physician. 

Section  2.  Every  school  physician  shall  make  a  prompt 
examination  and  diagnosis  of  all  children  referred  to  him 


Legal  Aspects  of  Medical  Inspection  163 

as  hereinafter  provided,  and  such  further  examination  of 
teachers,  janitors,  and  school  buildings  as  in  his  opinion 
the  protection  of  the  health  of  the  pupils  may  require. 

Section  3.  The  school  committee  shall  cause  to  be 
referred  to  a  school  physician  for  examination  and  diag- 
nosis every  child  returning  to  school  without  a  certificate 
from  the  board  of  health  after  absence  on  account  of  illness 
or  from  unknown  cause;  and  every  child  in  the  schools 
under  its  jurisdiction  who  shows  signs  of  being  in  ill 
health  or  of  suffering  from  infectious  or  contagious 
disease,  unless  he  is  at  once  excluded  from  school  by  the 
teacher;  except  that  in  the  case  of  schools  in  remote 
and  isolated  situations  the  school  committee  may  make 
such  other  arrangements  as  may  best  carry  out  the  pur- 
poses of  this  act. 

Section  4.  The  school  committee  shall  cause  notice  of 
the  disease  or  defects,  if  any,  from  which  any  child  is 
found  to  be  suffering  to  be  sent  to  his  parent  or  guardian. 
Whenever  a  child  shows  symptoms  of  smallpox,  scarlet 
fever,  measles,  chickenpox,  tuberculosis,  diphtheria  or 
influenza,  tonsillitis,  whooping  cough,  mumps,  scabies,  or 
trachoma,  he  shall  be  sent  home  immediately,  or  as  soon 
as  safe  and  proper  conveyance  can  be  found,  and  the  board 
of  health  shall  at  once  be  notified. 

Section  5.  The  school  committee  of  every  city  and 
town  shall  cause  every  child  in  the  public  schools  to  be 
separately  and  carefully  tested  and  examined  at  least 
once  in  every  school  year  to  ascertain  whether  he  is  suf- 
fering from  defective  sight  or  hearing  or  from  any  other 
disability  or  defect  tending  to  prevent  his  receiving  the 
full  benefit  of  his  school  work,  or  requiring  a  modifica- 
tion of  the  school  work  in  order  to  prevent  injury  to  the 
child  or  to  secure  the  best  educational  results.  The  tests 
of  sight  and  hearing  shall  be  made  by  teachers.  The 
committee  shall  cause  notice  of  any  defect  or  disability 
requiring  treatment  to  be  sent  to  the  parent  or  guardian 
of  the  child,  and  shall  require  a  physical  record  of  each 


164  Medical  Inspection  of  Schools 

child  to  be  kept  in  such  form  as  the  state  board  of  educa- 
tion shall  prescribe. 

Section  6.  The  state  board  of  health  shall  prescribe 
the  directions  for  tests  of  sight  and  hearing  and  the  state 
board  of  education  shall,  after  consultation  with  the 
state  board  of  health,  prescribe  and  furnish  to  school 
committees  suitable  rules  of  instruction,  test  cards, 
blanks,  record  books,  and  other  useful  appliances  for 
carrying  out  the  purposes  of  this  act,  and  shall  provide 
for  pupils  in  the  normal  schools  instruction  and  practice  in 
the  best  methods  of  testing  the  sight  and  hearing  of 
children.  The  state  board  of  education  may  expend  dur- 
ing the  year  nineteen  hundred  and  six  a  sum  not  greater 
than  fifteen  hundred  dollars,  and  annually  thereafter  a 
sum  not  greater  than  five  hundred  dollars  for  the  pur- 
pose of  supplying  the  material  required  by  this  act. 

Section  7.  The  expense  which  a  city  or  town  may  incur 
by  virtue  of  the  authority  herein  vested  in  the  school  com- 
mittee or  board  of  health,  as  the  case  may  be,  shall  not  ex- 
ceed the  amount  appropriated  for  that  purpose  in  cities  by 
the  city  council  and  in  towns  by  a  town  meeting.  The 
appropriation  shall  precede  any  expenditiure  or  any  in- 
debtedness which  may  be  incurred  under  this  act,  and  the 
sum  appropriated  shall  be  deemed  a  sufficient  appropria- 
tion in  the  municipality  where  it  is  made.  Such  appropria- 
tion need  not  specify  to  what  section  of  the  act  it  shall  apply, 
and  may  be  voted  as  a  total  appropriation  to  be  applied  in 
carrying  out  the  purposes  of  the  act.     (Repealed  in  1908.) 

Section  8.  This  act  shall  take  effect  on  the  first  day  of 
September  in  the  year  nineteen  hundred  and  six.  (Ap- 
proved June  20,  1906.) 

It  will  be  noted  that  the  provisions  of  section  7  enabled  any  city  coun- 
cil or  town  meeting  to  render  ineffective  the  whole  medical  inspection 
law,  by  refusing  to  grant  a  proper  appropriation  therefor.  A  few  cities 
and  towns  availed  themselves  of  this  opportunity,  and  in  order  to  avoid 
this  possibiUty  the  legislature  of  1908  repealed  the  section. 


Legal  Aspects  of  Medical  Inspection  165 

Observe  that  the  English  statute  and  the  Massachusetts  statute  each 
make  medical  inspection  compulsory. 

Neither  includes  a  penal  provision  providing  for  procedure  against 
neglectful  parents  of  defective  children. 

In  these  two  essentials,  the  acts  are  similar. 

In  the  English  act,  the  education  authorities  are  charged  with  the 
administration  of  the  law.  In  Massachusetts,  the  school  authorities  in 
every  city  or  town  appoint  medical  examiners,  except  in  cities  where  the 
board  of  health  is  already  maintaining  or  shall  hereafter  maintain  such 
medical  inspection  as  the  act  requires.  In  this  latter  class  the  board  of 
health  appoints. 

In  the  Massachusetts  statute,  an  examination  of  each  pupil  is  pro- 
vided at  least  once  in  every  school  year  for  defective  sight  or  hearing,  or 
any  other  disability.  The  tests  are  given  by  the  teachers,  but  the  board 
of  health  prescribes  the  directions  for  tests.  Notices  of  defects  must  be 
sent  to  the  parents. 

In  the  English  statute,  there  is  no  expressed  provision  for  the  number 
of  medical  examinations,  but  as  has  hereinbefore  been  stated,  the  London 
Board  of  Education  has  prescribed  three  examinations  during  a  school 
life  as  necessary. 

These  are  the  leading  statutes  in  Europe  and  America  upon  this  sub- 
ject. The  American  statute  has  been  in  effect  for  less  than  two  years,  the 
English  statute  a  little  over  one-half  year.  Neither,  therefore,  can  be 
considered  as  yet  away  from  the  experimental  stage  of  legislation. 

Let  us  now  consider  the  work  of  medical  inspection  done  without 
specific  mandatory  legislative  enactment,  and  done  under  the  existing 
permissive  provisions  of  the  Public  Health  Laws  of  the  State  of  New 
York,  in  the  most  populous  city  of  America. 

New  York  state  has  no  specific  statute  making  medical  inspection 
compulsory.  Such  inspection  is  conducted  in  the  city  of  New  York  by 
the  Department  of  Health  under  the  general  authority  of  the  PubUc 
Health  Laws,  authorizing  local  health  boards  to  guard  against  the  intro- 
duction of  contagious  and  infectious  diseases  by  the  exercise  of  proper  and 
vigilant  medical  inspection,  and  the  control  of  all  persons  and  things 
arriving  in  the  municipality  from  infected  places,  or  which  from  any  cause 
are  liable  to  communicate  contagion.  This  statute  is  Section  24  of  Arti- 
cle 2  of  Chapter  661  of  the  Laws  of  1893  and  amendments  thereto. 


i66  Medical  Inspection  of  Schools 

Section  210  of  Article  12  of  the  same  statute  makes  the  vaccination  of 
school  children  compulsory. 

To  show  the  attitude  of  the  people  of  New  York,  it  may  be  said  that 
the  enforcement  of  this  section  was  bitterly  contested  to  the  Court  of  Final 
Appeal,  where  its  constitutionality  was  affirmed  in  October,  1901. 

Although  no  legislative  enactment  yet  appears  upon  the  statute  books 
of  New  York  in  regard  to  compulsory  medical  inspection  of  school  chil- 
dren, more  consideration  has  been  displayed  in  section  213  of  Article  12  of 
the  same  law,  in  regard  to  the  examination  and  quarantine  of  children 
admitted  to  institutions  for  orphans,  destitute  or  vagrant  children,  or 
juvenile  delinquents. 

This  section  provides: 

"Every  institution  in  this  state,  incorporated  for  the 
express  purpose  of  receiving  or  caring  for  orphan,  vagrant 
or  destitute  children  or  juvenile  delinquents,  except  hos- 
pitals, shall  have  attached  thereto  a  regular  physician  of 
its  selection  duly  licensed  under  the  laws  of  the  state  and 
in  good  professional  standing,  whose  name  and  address 
shall  be  kept  posted  conspicuously  within  such  institution 
near  its  main  entrance.  The  words  'juvenile  delin- 
quents' here  used  shall  include  all  children  whose  com- 
mitment to  an  institution  is  authorized  by  the  penal  code. 
The  officers  of  every  such  institution  upon  receiving  a  child 
therein,  by  commitment  or  otherwise,  shall,  before  ad- 
mitting it  to  contact  with  the  other  inmates,  cause  it  to  be 
examined  by  such  physician,  and  a  written  certificate  to  be 
given  by  him,  stating  whether  the  child  has  diphtheria, 
scarlet  fever,  measles,  whooping  cough  or  any  other  con- 
tagious or  infectious  disease,  especially  of  the  eyes  and  skin, 
which  might  be  communicated  to  other  inmates  and  speci- 
fying the  physical  and  mental  condition  of  the  child,  the 
presence  of  any  indication  of  hereditary  or  other  consti- 
tutional disease,  and  any  deformity  or  abnormal  condition 
found  upon  the  examination  to  exist.  No  child  shall  be  so 
admitted  until  such  certificate  shall  have  been  furnished, 
which  shall  be  filed  with  the  commitment  or  other  papers 


Legal  Aspects  of  Medical  Inspection  167 

on  record  in  the  case,  by  the  officers  of  the  institution,  who 
shall,  on  receiving  such  child,  place  it  in  strict  quarantine 
thereafter  from  the  other  inmates,  until  discharged  from 
such  quarantine  by  such  physician,  who  shall  thereupon 
indorse  upon  the  certificate  the  length  of  quarantine  and 
the  date  of  discharge  therefrom." 

"Section  214.  Monthly  examination  of  inmates  and 
reports. — Such  physician  shall  at  least  once  a  month 
thoroughly  examine  and  inspect  the  entire  institution,  and 
report  in  writing,  in  such  form  as  may  be  approved  by  the 
state  department  of  health,  to  the  board  of  managers  or 
directors  of  the  institution,  and  to  the  local  board  of  the 
district  or  place  where  the  institution  is  situated,  its  condi- 
dition,  especially  as  to  its  plumbing,  sinks,  water-closets, 
urinals,  privies,  dormitories,  the  physical  condition  of  the 
children,  the  existence  of  any  contagious  or  infectious 
disease,  particularly  of  the  eyes  or  skin,  their  food,  clothing 
and  cleanliness,  and  whether  the  officers  of  the  institution 
have  provided  proper  and  sufficient  nurses,  orderlies,  and 
other  attendants  of  proper  capacity  to  attend  to  such  chil- 
dren, to  secure  to  them  due  and  proper  care  and  attention 
as  to  their  personal  cleanliness  and  health,  with  such 
recommendations  for  the  improvement  thereof  as  he  may 
deem  proper.  Such  boards  of  health  shall  immediately 
investigate  any  complaint  against  the  management  of  the 
institution  or  of  the  existence  of  anything  therein  danger- 
ous to  life  or  health,  and,  if  proven  to  be  well  founded  shall 
cause  the  evil  to  be  remedied  without  delay." 

The  penal  provisions  of  the  Health  Law  in  regard  to  violations 
thereof  provide : 

"Section  397.  Wilful  violation  of  Health  Laws. — i.  A 
person  who  wilfully  violates  or  refuses  or  omits  to  comply 
with  any  lawful  order  or  regulation  prescribed  by  any 
local  board  of  health  or  local  health  officer,  is  guilty  of  a 
misdemeanor. 

"  2.  A  person  who  wilfully  violates  any  provision  of  the 


1 68  Medical  Inspection  of  Schools 

health  laws,  or  any  regulation  lawfully  made  or  established 
by  any  public  officer  or  board  under  authority  of  the  health 
laws  the  punishment  for  violating  which  is  not  otherwise 
prescribed  by  those  laws,  or  by  this  code,  is  punishable  by 
imprisonment  not  exceeding  one  year,  or  by  a  fine  not 
exceeding  two  thousand  dollars  or  by  both." 

The  Public  Health  Laws  of  the  State  of  New  York  are  sufficiently 
broad  and  comprehensive  in  their  general  authorizing  provisions  to 
warrant  the  establishment  and  maintenance  by  the  health  authorities 
of  an  adequate  system  of  medical  inspection  of  school  children.  Hearty 
cooperation  on  the  part  of  the  education  authorities  is  essential,  how- 
ever, to  make  the  work  effective. 

In  1892,  medical  inspection  in  the  parochial  schools  of  Philadelphia 
was  established  and  was  soon  discontinued  on  account  of  much  opposi- 
tion thereto. 

In  1890,  Boston  ordered  such  medical  inspection,  but  did  not  enforce 
it  imtil  1894. 

In  1895,  Chicago  followed  suit. 

The  principle  upon  which  medical  inspection  of  schools  was  estab- 
lished in  these  cities,  and  in  fact  the  principle  upon  which  medical 
inspection  has  proceeded  in  all  of  the  states  in  the  Union,  has  been  the 
prevention  and  elimination  of  infectious  and  contagious  diseases,  and 
not  upon  the  high  intellectual  plane  upon  which  the  Board  of  Educa- 
tion of  London  in  the  memorandum  before  referred  to  have  placed  the 
reasons  for  the  enactment  of  their  legislation  in  the  following  words : 

"The  Board  desires,  therefore,  at  the  outset  to  emphasize 
that  this  new  legislation  aims  not  merely  at  a  physical  or 
anthropometric  survey,  or  at  a  record  of  defects  disclosed 
by  medical  inspection,  but  at  the  physical  improvement, 
and,  as  a  natural  corollary,  the  mental  and  moral  improve- 
ment, of  coming  generations.  The  broad  requirements  of 
a  healthy  life  are  comparatively  few  and  elementary,  but 
they  are  essential,  and  should  not  be  regarded  as  applicable 
only  to  the  case  of  the  rich.  In  point  of  fact,  if  rightly 
administered,  the  new  enactment  is  economical  in  the  best 
sense  of  the  word.     Its  justification  is  not  to  be  measured 


Legal  Aspects  of  Medical  Inspection  169 

in  terms  of  money,  but  in  the  decrease  of  sickness  and 
incapacity  among  children,  and  in  the  ultimate  decrease  of 
inefficiency  and  poverty  in  after  life  arising  from  physical 
disabihties." 

In  1897,  150  physicians  were  appointed  by  the  Department  of  Health 
of  New  York  to  inspect  schools. 

In  1907,  there  were  166,  together  with  50  trained  nurses,  at  work. 

From  1897  to  1902,  the  efforts  of  these  physicians  were  directed  to 
excluding  children  with  infectious  and  contagious  diseases. 

In  1902,  each  child  was  personally  examined  once  a  week. 

In  1905,  the  examination  of  each  child  thoroughly  to  ascertain  the 
existence  of  any  contagious  affection  was  instituted. 

No  child  was  treated  whose  parents  were  able  to  employ  physicians. 

The  fundamental  principles  in  force  at  that  time  were : 

1.  Repeated  and  systematic  inspection  of  all  school  children  for  the 
purpose  of  early  recognition  of  contagious  diseases. 

2.  Exclusion  from  school  attendance  of  all  children  affected  with  an 
acute  contagious  disease. 

3.  Subsequent  control  of  case  with  isolation  of  patient  and  disinfec- 
tion of  the  living  apartment  after  termination  of  illness. 

4.  Control  and  enforced  treatment  of  minor  contagious  ailments 
with  the  purpose  of  diminishing  the  number  of  children  excluded  from 
school  attendance. 

5.  Knowledge  of  unreported  cases  of  contagious  diseases. 

6.  Complete  physical  examination  of  each  school  child  with  reference 
to  the  existence  of  any  physical  or  mental  abnormality. 

The  working  officers  consisted  of  a  chief  medical  inspector,  a  corps 
of  physician  inspectors,  a  supervising  nurse,  and  a  corps  of  trained 
nurses. 

In  the  English  statute  there  is  no  provision  for  the  employment  of 
school  nurses,  but  such  employment  is  recommended  wherever  feasible. 

It  seems  to  be  the  general  opinion  of  hygienic  experts  that  admirable 
results  in  the  furtherance  of  medical  inspection,  especially  in  the  home 
treatment  of  defective  children,  have  been  obtained  by  the  employment 
of  school  nurses. 

Under  the  regulations  of  the  New  York  Health  Department,  eacli 


170  Medical  Inspection  of  Schools 

physician  inspector  visited  a  group  of  schools  before  ten  in  the  morning 
and  examined: 

1.  All  children  isolated  by  the  teachers  suspected  of  contagious 
diseases. 

2.  All  children  who  had  been  absent  from  school  for  any  reason. 

3.  All  affected  children  neglecting  treatment. 

4.  All  cases  referred  by  the  school  nurse  for  diagnosis. 

Upon  diagnosis  of  contagious  disease,  the  child  was  sent  home  and 
could  not  return  to  the  school  except  on  the  certificate  of  th-e  Depart- 
ment of  Health  as  to  the  termination  of  the  disease. 

Children  suffering  from  skin  diseases  were  ordered  to  go  to  their 
family  physician,  or  to  dispensaries,  or  to  the  school  nvu-se  for  treatment. 

The  niirses  were  assigned  to  schools  in  crowded  tenement  districts, 
and  treated  such  pupils  as  were  sent  to  them  by  the  medical  inspectors. 

Routine  weekly  inspections  were  also  made  by  the  nxirse. 

All  doubtful  cases  were  referred  for  diagnosis. 

In  1905,  the  nurses  treated  976,092  cases. 

Two  dispensaries  and  one  hospital  for  trachoma  were  established. 

Absentees  were  visited  by  the  physicians  and  by  the  nurses. 

The  Superintendent  of  Schools  of  New  York  in  his  annual  report 
for  1907,  has  recommended  legislation  establishing  a  Department  of 
Hygiene,  to  be  placed  under  the  sole  and  exclusive  jiu-isdiction  of  the 
education  authorities  as  the  most  important  and  necessary  work  to  be 
accomplished  at  the  present  time  by  the  Board  of  Education. 

Here  is  food  for  expert  thought. 

Specific,  compulsory  legislation  authorizing  the  education  authori- 
ties in  the  city  of  New  York  to  conduct  medical  inspection  is  suggested 
by  the  chief  executive  officer  of  the  city  schools,  in  the  greatest  city 
in  the  country.     Dual  responsibility  is  deprecated. 

On  the  side  of  the  sole  jurisdiction  of  the  education  authorities 
stands  the  English  statute. 

The  tendency  of  the  Massachusetts  statute  is  to  put  the  jurisdiction 
in  the  education  authorities.  In  the  latter,  however,  there  is  co- 
ordinate reference  to  the  health  authorities. 

It  will  be  interesting  to  observe  the  measure  presented  for  enactment 
in  the  state  of  New  York,  after  due  and  proper  discussion  on  the  subject 
from  all  points  of  view. 


Legal  Aspects  of  Medical  Inspection  171 

None  of  the  other  states  of  the  Union  have  specific  statutes  making 
medical  inspection  mandatory. 

New  Jersey  has  a  statute  making  medical  inspection  permissible. 
This  statute  went  into  effect  on  October  19,  1903.  It  is  Section  229 
of  Article  27  of  the  School  Laws,  and  is  as  follows: 

"Medical  Inspector.    Duties. — 229.     Every  Board  of 

Education  may  employ  a  competent  physician  to  be 
known  as  the  medical  inspector,  fijc  his  salary  and  define 
his  duties.  Said  medical  inspector  shall  visit  the  schools 
in  the  district  in  which  he  shall  be  employed  at  stated 
times  to  be  determined  by  the  board  of  education,  and 
during  such  visits  shall  examine  every  pupil  referred  to 
him  by  a  teacher.  He  shall  at  least  once  during  each 
school  year  examine  every  pupil  to  learn  whether  any 
physical  defect  exists,  and  keep  a  record  from  year  to  year 
of  the  growth  and  development  of  such  pupil,  which  record 
shall  be  the  property  of  the  board  of  education  and  shall 
be  delivered  by  said  medical  inspector  to  his  successor  in 
office.  Said  inspector  shall  lecture  before  the  teachers  at 
such  times  as  may  be  designated  by  the  board  of  education, 
instructing  them  concerning  the  methods  employed  to 
detect  the  first  signs  of  communicable  disease  and  the 
recognized  measiu"es  for  the  promotion  of  health  and  pre- 
vention of  disease.  The  board  of  education  may  appoint 
more  than  one  medical  inspector." 

Vaccination  is  compulsory  vmder  the  same  statute,  as  it  is  in  most 
states. 

The  superintendent  of  the  city  schools  of  Newark  is  authority 
for  the  statement  that  there  has  been  medical  inspection  in  Newark 
for  seven  years  last  past. 

The  weak  point  in  the  New  Jersey  law,  in  his  opinion,  consists  in 
the  lack  of  authority  vested  in  the  Board  of  Health  or  in  the  Board  of 
Education  to  compel  parents  to  give  suitable  treatment  to  those  children 
excluded  from  school  because  of  physical  defects  needing  siu-gical  treat- 
ment, etc. 


172  Medical  Inspection  of  Schools 

He  also  says : 

"  It  is  the  purpose  of  the  Board  of  Education  of  this  city 
to  take  over  the  full  control  of  medical  inspection  of  pupils 
combined  with  the  approval  of  the  Board  of  Health, 
which  until  now  has  shared  responsibility.  There  are 
several  important  reasons  with  us  why  it  is  desirable  that 
the  Board  of  Education  should  have  the  sole  responsibility 
in  the  matter  of  medical  inspection  and  treatment  of 
school  pupils." 

In  Newark  medical  inspectors  are  by  Section  II  of  the  Board  of 
Education  instructions  at  all  times  under  the  immediate  direction  and 
control  of  the  Board  of  Health  in  all  matters  pertaining  to  the  per- 
formance of  their  duties.  They  are  required  to  make  a  daily  report  to 
the  Board  of  Health. 

The  matter  of  more  thorough  inspection  is  now  under  consideration 
in  New  Jersey. 

In  the  belief  that  the  legal  status  of  medical  inspection  in  the  more 
progressive  states  of  the  Union,  and  the  lack  of  the  same  in  other  states, 
might  be  interesting  and  perhaps  helpful,  an  attempt  has  been  made  to 
collate  the  information  relating  thereto  furnished  by  the  health  and 
education  authorities  of  the  various  state  governments. 

In  Maryland  there  is  no  statutor}'^  requirement  for  individual  inspec- 
tion and  medical  treatment  of  school  children.  In  Baltimore  there  is 
medical  inspection  under  the  city  ordinances. 

Section  5  of  Article  43  of  the  Code  of  Public  Health  Laws  of  Mary- 
land provides,  in  reference  to  the  duties  of  the  Secretary  of  the  State 
Board  of  Health,  that  "He  shall  when  requested  by  local  boards  visit 
their  respective  districts,  cities  or  villages,  investigate  the  cause  of  any 
existing  disease,  and  shall  from  time  to  time  and  whenever  directed  by 
the  Governor  or  legislature  make  special  inspections  of  public  hospitals, 

asylums,  prisons  and  other  institutions,  and  shall when 

required  by  the  Governor  or  other  proper  authorities  advise  in  regard 

to  the  location,  drainage,  water  supply and  ventilation 

of  any  public  institution " 

Section  22,  same  article,  provides  that  "the  board  of  County  Com- 
missioners in  the  several  counties  in  this  State  shall  ex  officio  constitute  a 


Legal  Aspects  of  Medical  Inspection  173 

local  board  of  health  for  their  respective  counties  and  shall  have  and 
exercise  all  the  duties  of  a  board  of  health  as  provided  in  this  article. 


The  general  authority  to  make  such  inspections  under  the  Public 
Health  Laws  is  given  to  the  state  and  local  boards  of  health. 

The  secretary  of  the  State  Board  of  Health  does  not  believe  it  ex- 
pedient to  provide  special  legislation  for  the  purpose  of  sanitary  inspec- 
tion of  schools  if  the  general  statutes  give  the  necessary  power. 

He  is  also  of  the  opinion  that  individual  attention  to  the  health  of 
school  children  is  best  provided  for  by  local  ordinances  or  regulations. 

In  Pennsylvania  there  is  no  legislation  relative  to  medical  and  sani- 
tary inspection  of  public  schools. 

In  the  niral  districts  the  State  Department  of  Health  has  considered 
that,  in  its  duty  to  protect  the  health  of  the  public  generally,  it  should 
make  sanitary  inspections,  inasmuch  as  this  matter  appeared  to  be 
entirely  neglected.  In  Philadelphia  the  local  Board  of  Education  has 
taken  up  the  matter  with  the  assistance  of  the  local  Board  of  Health. 

In  Philadelphia  school  nursing  has  also  received  some  attention, 
but  so  far  as  the  action  of  the  State  Legislature  is  concerned,  nothing 
has  been  done. 

The  view  of  the  Assistant  Commissioner  of  Health  in  Pennsylvania 
is  that  sanitary  inspection,  referring  to  construction,  location,  etc., 
is  a.  proper  fimction  of  the  Board  of  Education,  and  that  the  medical 
inspection,  which  involves  the  examination  of  pupils  by  physicians, 
should  be  undertaken  by  the  Board  of  Health. 

The  chief  of  the  Bureau  of  Health  of  the  city  of  Philadelphia  says 
that  the  work  in  Philadelphia  was  the  outcome  of  an  agreement  between 
the  Bureau  of  Health  and  the  Board  of  Education,  and  approved  by 
City  Councils,  who  furnished  the  means  for  the  conduct  of  the  work. 

In  so  far  as  the  treatment  of  children  found  in  the  schools  suffering 
from  disease  is  concerned,  the  great  majority  of  them  are  looked  after 
by  their  parents.  Those  who  cannot  be  looked  after  by  their  parents, 
are  attended  by  the  district  physician  or  by  some  one  or  another  of  the 
hospitals  in  the  city. 

Children  having  defective  vision,  who  are  in  such  destitute  circum- 
stances that  their  parents  cannot  provide  necessary  relief,  are  relieved 
by  this  Bureau  at  the  city's  expense. 


174  Medical  Inspection  of  Schools 

The  Bureau  has  an  expert  ophthalmologist  making  examinations, 
and  money  is  provided  for  the  purchase  of  glasses. 

The  chief  is  an  advocate  of  school  inspection.  He  believes  it  is 
only  partially  successful. 

He  thinks  it  is  unsatisfactory,  that  continuously,  in  the  schools  of 
their  city,  children  are  found  who  should  be  under  the  care  of  specialists ; 
some  of  them  requiring  orthopedic  corrections,  some  of  them  mentally 
enfeebled,  and  some  epileptic,  and  others  suffering  from  similar  afflic- 
tions. These  cases  cannot  be  properly  looked  after  by  the  means  at  the 
Biu-eau's  disposal.  He  suggests  special  schools  for  children  who  are 
abnormal  in  any  particular. 

The  Bureau  has  no  difl&culty  with  children  who  are  acutely  sick. 
If  their  parents  pay  no  attention  to  their  condition,  it  is  within  the  power 
of  the  Bureau  to  convey  them  to  one  or  another  of  the  hospitals  under 
the  Bureau's  control. 

In  Illinois  there  is  no  specific  legislation  relative  to  sanitary  and 
medical  inspection  of  public  schools. 

The  local  boards  of  health  throughout  the  state  are  legally  em- 
powered to  inaugurate  and  carry  on  such  inspections.  There  is  no  law 
legalizing  inspection  of  pupils  in  schools.  Chicago  has  city  ordinances 
under  which  sanitary  inspection  of  school  buildings  is  carried  out.  Also 
medical  inspection  of  school  pupils  for  the  purpose  of  keeping  out 
infectious  diseases.  There  is  no  examination  for  physical  or  mental 
defects  at  present.  The  law  does  not  authorize  such.  The  medical 
inspector  of  the  Department  of  Health,  however,  states  that  the  Depart- 
ment of  Health  expects  to  try  making  such  examinations  and  to  endeavor 
to  show  results  which  wiU  justify  making  laws  legalizing  such  work. 

In  the  District  of  Columbia  there  is  medical  inspection  under  rules 
formulated  by  the  health  officer  in  1903,  and  approved  by  the  Board  of 
Education,  in  accordance  with  an  act  making  appropriations  to  provide 
for  the  expenses  of  the  government  of  the  District  of  Columbia.  They 
were  amended  in  1907. 

These  rules  have  the  full  legal  force  and  effect  of  law. 

In  regard  to  inspection,  the  health  officer  says : 

"  School  niirsing  has  not  yet  been  provided  in  this  Dis- 
trict, but  the  Commissioners  have  recommended  that  an 


Legal  Aspects  of  Medical  Inspection  175 

appropriation  be  made  for  the  services  of  two  nurses  to 
operate  in  connection  with  the  medical  inspectors  of 
schools.  The  only  present  means  of  enforcing  the  parental 
obligation  to  provide  treatment  for  school  children  after 
exclusion  from  school  is  through  the  truancy  act.  If  a 
child  is  excluded  and  a  parent  does  not  adopt  such  meas- 
ures as  may  be  necessary  to  permit  it  to  return  to  school,  it 
might,  if  the  measiu-es  to  be  adopted  are  reasonable  and 
within  the  reach  of  the  parent,  be  possible  to  compel  action 
by  the  parent  by  prosecution  for  failing  to  send  the  child 
to  school.  This  procedure  has,  however,  not  yet  been 
tried  in  court,  although  the  possibility  of  it  has  been  a 
weapon  effectually  used  in  certain  cases. 

"  In  my  judgment,  it  is  quite  as  important  for  the  state 
to  look  after  the  physical  welfare  of  its  children  as  it  is  for 
it  to  provide  for  their  mental  training,  and  I  feel  that  justi- 
fication could  be  found  in  the  laws  of  most  jurisdictions 
for  every  proper  means  toward  that  end;  not  necessarily 
existing  statutes  or  regulations,  but,  if  not,  then  warrant 
in  the  constitution,  federal  and  state,  for  the  enactment  of 
such  statutes  and  the  promulgation  of  such  regulations. 
The  supreme  authority  which  the  state  may  exercise  with 
respect  to  the  physical  welfare  of  pupils  in  attendance  on 
public  schools  is  shown,  I  believe,  by  the  general  trend 
of  decisions  in  cases  in  which  vaccination  has  been  required 
as  a  condition  precedent  to  school  attendance." 

The  regulations  governing  the  medical  inspection  of  public  schools  in 
the  District  of  Columbia  provide  for  an  examination  by  the  teacher,  and 
if  any  indications  of  defects  or  disease  are  discovered  by  her  lay  mind, 
the  medical  inspector  must  be  summoned. 

The  medical  inspector  is  required  also  to  make  perfunctor)^  routine 
visits  to  the  schools. 

No  physical  examination  of  the  pupils  of  any  entire  room  or  building 
is  to  be  imdertaken  except  so  far  as  may  be  necessary  for  the  detection 
of  communicative  diseases  and  defects  of  sight  and  hearing,  without  the 
consent  of  the  Board  of  Education. 


176  Medical  Inspection  of  Schools 

California. — There  is  but  one  law  on  the  statute  books  of  this  State 
for  medical  attention  to  be  bestowed  upon  public  schools  children. 

Many  years  ago  a  special  act  providing  that  no  Board  of  School 
Trustees  or  Boards  of  Education  shall  permit  any  child  to  attend  the 
public  school  who  fails  to  show  satisfactory  evidence  of  vaccination, 
was  enacted.  The  law  met  with  much  opposition.  At  each  session  of 
the  Legislature  its  repeal  is  attempted.  At  Berkeley  (site  of  State  Uni- 
versity) the  anti-vaccinationists  operate  a  school  for  their  own  children 
at  their  own  expense. 

This  information  is  from  R.  H.  Webster,  Deputy  Superintendent  of 
the  Schools  of  San  Francisco. 

Mr.  Webster  thinks  there  should  be  systematized  medical  inspection 
of  children  attending  the  public  schools,  and  further  that  necessary 
treatment  be  provided  in  case  that  the  parent  or  guardian  of  a  child  is 
in  indigent  circumstances. 

The  matter  is  being  considered  in  some  cities,  notably  Los  Angeles. 

A  bill  will  be  introduced  into  the  next  Legislature. 

Colorado. — There  are  no  laws  relative  to  medical  and  sanitary 
inspection  of  schools  by  boards  of  health. 

General  statutes  creating  the  state  and  local  boards  of  health  give 
necessary  power. 

The  local  health  officers  of  the  various  towns  and  coimties  maintain 
supervision  over  the  schools  in  their  districts  for  the  prevention  of  con- 
tagious and  infectious  diseases. 

The  Health  Department  at  Denver  arranges  for  an  examination  of 
the  pupils  in  the  various  schools  at  stated  times. 

The  Health  Board  of  the  state  has  insufficient  funds  to  go  into  the 
work  as  thoroughly  as  they  should. 

Connecticut. — The  Legislature  of  Connecticut,  in  1899,  passed  a 
law  providing  for  the  testing  of  eyesight  in  all  the  public  schools  of  the 
state.  Under  the  law,  the  State  Board  of  Education  is  required  to 
furnish  test  cards  and  blanks  and  instructions  for  their  use  to  the  school 
authorities.  The  superintendent,  principal,  or  teacher  in  every  school 
is  required  to  test  the  eyesight  of  all  the  pupils  during  the  fall  term  and 
notify  in  writing  the  parent  or  guardian  of  every  pupil  who  has  any 
defect  of  vision,  with  a  brief  statement  of  each  defect.  The  tests  are 
made  triennially.     The  boards  of  education  and  school  committees 


Legal  Aspects  of  Medical  Inspection  177 

in  the  several  towns  of  the  state,  under  the  authority  granted  in  the 
general  statutes,  may  appoint  physicians  to  act  as  school  inspectors. 

Florida. — There  are  no  statutes  looking  to  the  protection  of  school 
children  either  in  the  construction  of  school  houses  or  in  the  examina- 
tion of  the  pupils. 

In  1907,  an  effort  was  made  by  the  State  Board  of  Health  to  obtain 
some  general  legislation  in  regard  to  health  and  sanitary  matters,  but, 
in  the  language  of  the  secretary,  who  is  the  State  Health  Officer:  "A 
difficulty  exists  always  in  trj-ing  to  acquire  legislation  of  this  kind  which 
has  no  political  significance  or  interest  to  the  politicians,  and  the  failure 
of  the  State  Board  of  Health  to  better  the  sanitary  and  health  condition 
of  the  people  in  this  direction  through  legislative  enactment  was  due 
altogether  to  these  causes,  and  not  to  any  interest  or  efforts  on  the  part 
of  the  Board  to  effect  the  same." 

Georgia. — No  legislation.    The  secretary  of  the  Health  Board  says: 

"  The  matter  of  public  hygiene  has  been  given  practic- 
ally no  consideration  in  this  part  of  the  coimtry  as  yet, 
though  I  trust  that  in  the  future  it  will  receive  more  atten- 
tion. There  is  no  question  of  the  fact  that  there  is  great 
need  of  such  legislation,  but  I  see  very  little  hope  of  any- 
thing being  done  in  that  line  in  the  near  future  in  this 
state." 

Idaho. — The  State  Board  of  Health  was  organized  in  1907.  There 
is  a  local  board  of  health  in  each  covmty,  consisting  of  the  county  physi- 
cian and  the  cotmty  commissioners.  The  State  Board  requires  the 
inspection  of  public  school  houses  as  to  their  sanitary  condition  twice  a 
year. 

There  is  no  law  covering  the  inspection  of  school  children. 

Indiana. — The  secretary  of  the  State  Board  of  Health  tells  Indiana's 
story  in  the  following  words : 

"Your  letter  received  asking  information  concerning 
Indiana's  Statutes  which  refer  to  the  medical  inspection  of 
school  children.  There  is  not  a  single  statute  relative  to 
this  subject  in  Indiana.     We  simply  let  our  defective  and 


lyS  Medical  Inspection  of  Schools 

sick  children  die,  and  all  pleas  heretofore  made  to  our 
legislature  have  been  rejected.  We  hope  some  day  that 
Indiana  will  rise  above  this  barbarism  by  the  people  send- 
ing men  to  the  legislature  who  are  intelligent  and  pro- 
gressive enough  to  take  hold  of  this  great  and  important 
subject. 

"  We  are  sorry  that  Indiana  cannot  make  a  better  report. 
Indianapolis,  at  one  time,  had  medical  school  inspection, 
but  just  now,  there  is  a  quarrel  between  the  City  Council 
and  the  school  board,  as  to  who  shall  pay  the  bill,  and 
nothing  is  being  done.  Between  looking  after  the  health 
of  our  children  and  having  the  pleasure  of  a  quarrel  among 
politicians,  we  know  which  way  it  will  go." 

Indiana  boards  of  health,  however,  may  make  medical  inspection 
of  schools  under  the  general  statutes. 

Kansas. — No  legislation  requiring  medical  and  sanitary  inspection 
of  schools  by  boards  of  education. 

In  1906,  the  State  Board  of  Health  made  a  rule  requiring  a  critical 
sanitary  inspection  by  county  health  officers  of  every  public  school 
building  in  their  jurisdiction,  and  during  the  summer  vacation  requiring 
that  each  school  house  be  thoroughly  and  efficiently  fumigated  before 
the  fall  term  of  school  began.  This  rule  has  been  quite  generally  and 
effectively  put  into  execution  during  the  past  two  years,  and  many 
unsanitary  and  unwholesome  conditions  found  and  rectified. 

The  Board  of  Health  considers  that  there  is  much  need  for  special 
legislation  along  these  lines. 

In  1907  a  bill  providing  for  medical  inspection  was  defeated. 

Kentucky. — No  provision  has  been  made  by  the  state  or  city  for 
medical  and  sanitary  inspection  of  public  schools. 

At  the  last  meeting  of  the  Legislature  a  bill  was  introduced  providing 
for  medical  inspection  in  cities  of  the  first,  second  and  third  classes. 
This  bill  failed  of  passage  in  the  rush  of  business  at  the  end  of  the  session. 

Michigan. — No  specific  laws  relating  to  the  medical  and  sanitary 
inspection  of  schools.  No  obligation  upon  the  parents  or  municipality 
to  provide  treatment  when  a  child  having  some  contagious  disease  that 
is  dangerous  to  public  health  has  been  excluded  from  school. 


Legal  Aspects  of  Medical  Inspection  179 

Detroit  and  one  or  two  other  cities  have  inaugurated  medical  inspec- 
tion of  schools,  and  the  results  are  most  satisfactor}\ 

The  secretary  of  the  Board  of  Health  believes  that  there  should  be 
not  only  medical  inspection  of  the  pupils,  but  a  general  supervision  of 
buildings  and  grounds,  toilets,  heating,  ventilating,  and  all  the  conditions 
under  which  a  child  is  obliged  to  acquire  an  education. 

A  general  revision  of  the  health  laws  at  the  next  session  of  the  Legis- 
lature is  being  advocated. 

The  schools  of  Detroit  are  inspected  daily  by  physicians  appointed 
by  the  Board  of  Health.  There  are  27  inspectors,  each  receiving  a 
salary  of  $250  per  year.     The  physicians  do  not  prescribe. 

Minnesota. — The  State  Board  of  Health  advises  that  medical  inspec- 
tion is  to  be  made  throughout  the  state  wherever  possible,  but  under  the 
present  laws  school  inspection  cannot  be  insisted  upon. 

For  some  years,  the  Health  Board  has  tried  to  secure  the  examination 
of  the  eyes  and  ears  of  school  children  throughout  the  state.  In  the 
smaller  places,  the  Board  has  met  with  liberal  support,  but  the  larger 
cities,  Minneapolis  and  St.  Paul,  have  not  yet  fallen  into  line  in  this  work. 
Minneapolis,  during  the  winter  of  1907  and  1908,  has  endeavored  to 
introduce  school  inspection. 

Medical  inspection,  except  in  an  experimental  way,  has  not  been 
carried  on.  There  is  no  legislation,  except  that  cities  are  permitted  to 
introduce  medical  inspection  if  they  see  fit. 

The  Health  Commissioner  is  in  sympathy  w^ith  medical  inspection 
carried  on  primarily  as  an  aid  to  departments  of  health  in  the  early 
detection  of  all  kinds  of  contagious  diseases.  He  thinks  that  if  this 
should  be  pursued  to  the  extent  of  employment  of  school  nurses,  it  would 
prove  pernicious. 

Nebraska. — No  special  laws. 

"Nebraska,"  says  the  health  inspector  of  the  state,  "being  young 
and  but  lightly  populated,  and  having  abundance  of  pure  air,  does  not, 
perhaps,  stand  so  much  in  need  of  such  laws  as  you  of  the  east,  with 
your  dense  population  overcrowded  cities,  and  smoky  and  noxious 
atmosphere." 

New  Hampshire. — No  legislation  requiring  medical  inspection  or 
providing  treatment  after  inspection. 

No  legalized  system  of  sanitary  inspection. 


l8o  Medical  Inspection  of  Schools 

Sanitary  inspections  of  school  buildings  are  occasionally  made  by 
local  boards  of  health,  more  particularly  upon  complaint  of  parents, 
teachers,  or  school  boards. 

The  views  of  the  secretary  of  the  State  Board  of  Health  are  that 
medical  inspection  of  school  children  ought  to  be  made  everywhere, 
and  that  legal  responsibility  for  the  treatment  of  such  as  require  it  should 
be  placed  upon  parents,  if  able,  and  otherwise,  on  the  municipality. 

Ohio. — The  present  statutes  permit  boards  of  health  to  establish 
systems  of  medical  inspection  for  the  prevention  of  communicable 
diseases,  and  also  permit  such  boards  to  make  an  inspection  of  school 
buildings  twice  a  year  for  the  purpose  of  determining  conditions  of 
lighting,  ventilation,  etc.  There  is  nothing  mandatory  in  this  legislation 
and  it  is  not  likely  that  anything  concerning  this  matter  will  be  enacted 
during  the  present  session  of  the  Legislature. 

The  feeling  of  the  Board  of  Education  is  that  boards  of  education 
should  be  empowered  to  make  medical  examinations  of  all  school  children 
and  that  there  should  be  power  conferred  enabling  the  Board  to  require 
parents  to  do  whatever  is  found  necessary  following  such  examinations. 
At  the  present  time,  the  Board  invokes  the  Juvenile  Court  in  all  matters 
coming  to  our  attention.  They  are  enabled  on  the  charge  of  "neglect 
of  children"  to  bring  most  parents  to  time  in  these  matters. 

Oklahoma. — No  laws  at  present.  The  first  State  Legislature  now 
in  session. 

Oregon. — No  legislation  in  regard  to  medical  and  sanitary  inspection 
of  schools,  other  than  that  given  city,  county,  and  state  boards  of 
health  in  the  state  health  laws.  The  State  Board  of  Health  has  been  in 
existence  but  five  years. 

In  the  city  of  Portland  there  is  a  system  of  medical  inspection, 
the  inspection  being  given  by  various  doctors  throughout  the  city 
gratuitously. 

No  legalized  system  or  school  nursing. 

The  state  health  ofl5cer  believes  that  every  school  should  have 
thoroughly  competent  and  well  paid  physicians  to  make  regular  examina- 
tions of  all  school  children,  as  well  as  to  give  instructions  to  teachers 
relative  to  school  sanitation,  school  hygiene,  and  the  general  health  of 
the  children.  He  also  believes  that  this  system  should  be  carried  into 
the  country  school  districts. 


Legal  Aspects  of  Medical  Inspection  i8i 

Rhode  Island. — No  legislation.  Some  inspection  in  Providence  and 
Newport. 

Texas. — Sanitation  of  school  buildings  is  required.     No  other  laws. 

Local  school  boards  have  been  interested  in  eye  inspection,  and 
specialists  have  been  persuaded  to  make  these  examinations  without 
charge.  The  same  has  been  done  with  the  ear,  nose,  and  throat 
troubles. 

Texas  is  behind  in  these  matters,  but  shows  willingness  to  catch  up. 

Utah. — Legislation  expected  at  the  next  session  of  the  Legislature. 

The  State  Board  of  Health  has  provided  for  the  testing  of  the  eyes 
of  school  children,  and  also  examination  as  to  the  presence  of  defective 
hearing  and  of  mouth  breathing,  the  said  test  to  be  made  by  the  teacher, 
and  upon  the  discovery  of  any  of  the  defects  described,  reporting  the 
fact  to  the  parents  with  recommendation  that  the  child  shall  be  examined 
by  a  competent  specialist. 

The  State  Board  of  Health  is  also  preparing  rules  making  it  the  duty 
of  teachers  to  report  unsanitary  or  unhygienic  conditions  in  the  schools, 
including  improper  construction,  and  to  use  vigilance  in  the  detection  of 
symptoms  of  contagious  disease  among  the  pupils  and  the  immediate 
exclusion  of  any  pupil  suspected  of  being  so  affected. 

The  secretary  thinks  it  should  be  the  duty  of  all  parents  to  provide 
for  a  competent  physical  examination  of  children  before  permitting 
them  to  enter  school,  the  said  examination  to  determine  the  presence  of 
any  defect  requiring  correction.  He  also  thinks  that  the  state  should 
insist  that  the  correction  should  be  furnished  by  the  parent. 

The  last  Legislature  passed  a  law  requiring  the  introduction  in  the 
public  schools  and  in  the  normal  schools  of  a  course  of  instruction  on 
the  subject  of  preventable  disease  and  preventive  methods. 

Vermont. — No  special  legislation,  except  requirements  as  to  ven- 
tilation, light,  and  general  sanitary  conditions  in  school  buildings. 
Also  a  law  requiring  the  examination  of  the  eyes,  ears,  and  throats  of 
school  children  annually,  enacted  in  1904. 

The  secretary  of  the  State  Board  of  Health  says  that  it  is  very 
difficult  to  formulate  a  law  in  a  rural  state  like  Vermont,  where,  outside 
of  a  few  large  towns,  the  schools  are  small  and  widely  scattered. 

South  Carolina. — No  legislation,  aside  from  general  statutes. 

The  State  Board  of  Inspectors,  the  public  schools,  and  the  State 


1 82  Medical  Inspection  of  Schools 

Board  of  Health  are  now  inaugurating  a  system  to  protect  the  eyes  and 
ears  of  school  children. 

"Washington. — No  general  laws. 

In  the  larger  cities  the  matter  is  more  or  less  covered  by  city  ordin- 
ances and  board  of  health  regulations. 

Wisconsin. — Very  little  definite  legislation  regarding  school  inspec- 
tion. 

The  State  Board  of  Health  is  empowered  under  the  general  law 
to  make  obser^'ations  and  enforce  proper  sanitary  care  of  school 
houses. 

The  State  Board  of  Health  has  endeavored  through  inspectors  to 
see  that  the  school  houses  were  properly  heated,  ventilated,  and  lighted. 

No  provision  has  been  made  for  treatment  of  school  children  after 
such  inspection. 

No  legalized  system  of  school  nursing  or  legislation  on  subjects 
kindred  thereto. 

The  Board  is  endeavoring  to  formulate  methods  in  regard  to  the 
testing  of  eyes,  ears,  nose,  and  throat  of  school  children. 

This  question  will  probably  be  considered  at  the  1909  session  of  the 
State  Legislature. 

In  the  following  states  there  are  no  laws,  aside  from  the  general 
statutes,  upon  the  subjects  referred  to: 

Louisiana  Montana 

Maine  Nevada 

Mississippi  North  Dakota 

Missouri  South  Dakota 

In  the  following  states  inquiries  regarding  medical  inspection  were 
unanswered: 

Alabama  North  Carolina 

Arizona  Tennessee 

Arkansas  Virginia 

Delaware  West  Virginia 

Iowa  Wyoming 
New  Mexico 


Legal  Aspects  of  Medical  Inspection  183 

From  the  legal  domain  the  suggestions  prompted  by  the  foregoing 
study  are  the  following: 

Those  having  a  part  in  the  future  of  medical  inspection  should  exert 
themselves  to  the  utmost  to  secure  so  far  as  possible  uniformity  in 
statutory  provision. 

Legislation  should  provide  that  medical  inspection  shall  be  com- 
pulsory. 

That  local  conditions  determine  whether  the  onus  of  executing  the 
law  be  upon  the  health  or  the  education  authorities. 

Insert  a  penal  provision  compelling  parents  or  guardians  to  provide 
proper  medical  attention  upon  the  order  of  the  medical  examiner. 

Most  essential  of  all — insure  the  law's  enforcement. 


CHAPTER  XII 

Retardation  and  Physical  Defects 

EDUCATIONAL  ECONOMIES  EFFECTED  THROUGH 
MEDICAL  SUPERVISION 

The  memorandum  of  the  British  Board  of  Education  on  "Medical 
Inspection  of  Children  in  Public  Elementary  Schools,"  states  in  a  few 
brief  words  the  fundamental  basis  upon  which  medical  inspection  rests. 
Of  the  recent  English  law  it  says : 

"It  (the  law  of  1908)  is  foimded  on  a  recognition  of  the 
close  connection  which  exists  between  the  physical  and 
mental  condition  of  the  children  and  the  whole  process  of 
education.  It  recognizes  the  importance  of  a  satisfactory 
environment,  physical  and  educational,  and  by  bringing 
into  greater  prominence  the  effect  of  environment  upon  the 
personality  of  the  individual  child,  seeks  to  secure  ulti- 
mately for  every  child,  normal  or  defective,  conditions  of 
life  compatible  with  that  full  and  effective  development  of 
its  organic  fvmctions,  its  special  senses,  and  its  mental 
powers,  which  constitute  a  true  education." 

That  there  must  exist  a  close  relation  between  mental  and  physical 
conditions  no  one  will  deny,  but  how  important  the  relation  is  when 
measured  in  terms  of  its  efifect  on  the  educational  progress  of  school 
children,  and  whether  indeed  such  measurement  in  quantitative  terms 
is  possible,  are  problems  which  have  been  seldom  studied,  and  if  at  aU, 
in  the  most  casual  fashion. 

With  some  notable  exceptions,  those  who  have  occupied  themselves 
with  these  matters  have  assumed  that  there  exists  a  correlation  between 
school  progress  and  physical  defects  so  marked  and  so  direct  that  could 
we  but  correct  and  prevent  bodily  unsoimdn ess  among  the  pupils  of  our 

184 


Retardation  and  Physical  Defects  185 

schools,  we  should  thereby  at  once  do  away  with  "backwardness"  and 
"retardation." 

As  a  corollary  to  this  hoped  for  disappearance  of  retardation  not  a 
few  school  men  have  argued  that  great  financial  economies  would  be 
effected  and  such  evils  as  crowded  rooms  and  "half  time"  schools 
rendered  unnecessary.  In  some  places  this  view  has  led  to  earnest 
argument  in  favor  of  the  establishment  of  systems  of  medical  inspection, 
and  the  plea  has  been  made  that  the  expense  involved  would  be  more 
than  made  up  by  the  direct  financial  saving  effected.  An  example  is 
found  in  the  latest  annual  report  of  the  city  superintendent  of  schools  of 
one  of  the  large  New  England  cities.     He  pleads  his  case  as  follows : 

"Many  children  lose  promotion  and  are  compelled  to 
repeat  their  work.  Now,  it  costs  the  city  in  round  num- 
bers $230,000  to  educate  its  public  school  children.  The 
average  attendance  is  in  the  neighborhood  of  93  per  cent. — 
a  loss  of  7  per  cent,  on  account  of  absence.  Seven  per 
cent,  of  $230,000,  or  more  than  $16,000,  represents  the 
annual  waste  caused  by  absence  of  children  from  school. 
If  by  a  system  of  medical  inspection  this  per  cent,  of 
attendance  can  be  lifted  only  i  per  cent.,  it  would  amount 
to  a  saving  of  $1,600,  or  all  that  it  would  cost  to  secure 
good  inspection  for  a  city  like  ours." 

In  other  words,  the  superintendent  argues  that  if  every  day  94 
children  can  be  induced  to  attend  school  where  now  only  93  are  present, 
a  financial  saving  will  result  amounting  to  some  $1,600.  The  fallacy 
of  this  argument  is,  of  course,  evident;  but  it  is  nevertheless  one  which 
has  found  enthusiastic  support  in  many  places  and  which  has  been  widely 
used  \iy  the  advocates  of  medical  inspection. 

The  contention  that  a  successful  system  of  medical  inspection  would 
go  far  toward  eliminating  the  evil  of  "half  time,"  because  it  would  reduce 
the  amoimt  of  retardation  or  backwardness  in  our  school  systems,  rests 
on  an  equally  mistaken  basis.  Nevertheless,  this  argument,  too,  has 
been  eloquently  stated  and  actively  urged  in  many  quarters.  A  district 
superintendent  of  one  of  our  largest  cities,  an  eminent  and  able  educator, 
stated  the  argument  but  a  few  months  ago  in  a  discussion  of  retardation 
in  different  cities.     He  says: 


i86  Medical  Inspection  of  Schools 

"  Boston  is  now  able  to  make  the  proud  boast  that  she 
has  a  seat  in  school  for  every  child  able  to  attend.  This 
condition  may  in  part  be  due  to  the  smaller  percentage  of 
retardation.  Were  the  stream  of  children  through  the 
grades  less  rapid,  perhaps  she  would  have  thousands  and 
tens  of  thousands  upon  'part  time,'  while  empty  benches 
yawn  for  occupancy  in  the  highest  grades.  Damming  the 
stream  of  children  passing  through  the  grades  of  our 
schools  defeats  the  purpose  of  our  public  educational  sys- 
tem and  causes  a  wasteful  expenditure  of  public  funds." 

And  again :  \ 

"  The  child  that  takes  ten  years  to  complete  an  eight  year 
course  costs  the  state  25  per  cent,  more  than  the  one  that 
goes  through  on  time." 

Here  again  the  problem  of  retardation  is  brought  into  relation  to  the 
problems  of  accojnmodation  and  cost.  Inasmuch  as  a  principal  argu- 
ment of  the  advocates  of  med^eal  inspection  is  that  physical  defects  con- 
stitute a  potent  force  for  causing  retardation,  these  claims  are  of  the 
greatest  interest  in  the  present  discussion.  The  first  contention  in  the 
above  quotation  is  that  if  the  progress  of  the  children  through  the  grades 
in  the  city  referred  to  were  less  rapid  than  it  is,  there  would  as  a  conse- 
quence be  thousands  or  tens  of  thousands  of  pupils  upon  "part  time." 
At  first  sight  this  seems  a  perfectly  sound  contention ;  but  the  fact  of  the 
matter  is  that  the  children  who  do  not  progress  through  the  school  grades 
at  the  normal  rate,  and  hence  find  themselves  at  the  age  of  say  fourteen 
in  the  fifth  or  sixth  grade  instead  of  the  eighth,  do  not  as  a  rule  continue 
two  or  three  more  years  in  order  to  finish,  but  instead  drop  out  without 
completing  the  covu-se.  That  is  to  say,  a  city  must  have  enough  seats 
to  accommodate  all  of  its  children  between  the  ages  of  say  seven  and 
fourteen  years.  It  makes  little  difference  in  this  particular  problem  what 
progress  the  children  make:  the  necessity  for  accommodation  remains 
the  same,  whether  all  of  them  complete  the  eight  grades,  or  only  a  small 
percentage  do  so.  Under  all  circumstances  they  will  require  the  same 
number  of  seats.     Looking  at  it  from  the  standpoint  of  expenditure,  it  is 


Retardation  and  Physical  Defects  187 

jxist  as  plain  that  it  will  cost  fully  as  much  to  teach  them,  whether  they 
are  well  along  in  their  grades  and  studies,  or  far  behind. 

The  specific  case  mentioned  of  the  child  who  takes  ten  years  to  com- 
plete the  eight  year  course  sounds  convincing,  and  the  argument  is 
indeed  valid  when  this  actually  happens.  The  trouble  is,  however,  that 
the  case  mentioned  does  not  represent  the  average  or  even  a  common 
case.  In  practice  the  child — and  he  is  typical  of  a  far  larger  number 
than  the  general  public  commonly  supposes — does  not  take  ten  years  to 
finish  an  eight  year  course.     He  simply  drops  out  without  finishing. 

In  stating  these  aspects  of  the  problem  it  is  not  at  all  our  purpose  to 
minimize  the  evils  of  retardation  or  to  depffecate  the  benefits  to  be  gamed 
through  medical  inspection;  but  cost  and  overcrowding  are  not  evils  of 
retardation.  Financial  economies  are  not  directly  effected  through 
medical  inspection,  and  "part  time"  is  not  related  to  the  problem. 
"A  penny  saved  is  a  penny  earned"  only  when  the  saving  is  direct.  In 
the  case  of  medical  inspection  the  economies  effected  are  the  indirect 
ones  of  secxiring  greater  educational  retiims  for  the  expenditure  of  public 
funds  expended  to  support  the  schools,  and  the  still  more  indirect  saving 
effected  by  bringing  about  conditions  which  will  render  the  future 
citizens  of  the  state  more  efficient. 

The  fact  that  many  of  the  children  of  the  public  schools  never  reach 
the  eighth  grade  and,  therefore,  do  not  obtain  the  eight  years'  education 
which  the  common  school  system  provides,  long  known  to  educators, 
has  of  recent  years  received  considerable  attention  through  efforts  to 
measure  the  extent  of  this  tendency  and  to  discover,  if  possible,  its  under- 
lying causes.  These  efforts  have  been  more  or  less  scattered,  but  the 
appearance  of  such  discussions  in  dift'erent  parts  of  the  country'  indicates 
a  growing  feeling  among  educators  that  these  aspects  of  our  school 
administration  deserve  more  attention  than  they  have  hitherto  received. 
From  the  standpoint  of  a  comprehensive  study  of  the  problem  of  retar- 
dation it  is  quite  true  that  the  literature  of  the  subject  is  still  in  its  infancy, 
but  there  have  been  contributions  to  it  in  various  quarters  which  have 
thrown  considerable  light  upon  the  subject  in  its  various  aspects. 

To  a  considerable  extent  the  treatment  of  the  subject  has  been  statis- 
tical, and  one  might  say  more  or  less  unconscious  of  the  large  problems 
which  are  involved  in  it.  It  appears  in  this  form  in  the  reports  of  vari- 
ous school  systems  which  print  tables  showing  the  number  of  pupils 


i88  Medical  Inspection  of  Schools 

of  each  age  in  the  several  grades,  indicating  most  clearly  that  the  popula- 
tion of  a  grade  is  not  homogeneous,  but  is  composed  of  many  elements. 
A  few  facts  gathered  from  various  cities  were  published  in  the  report  of 
the  U.  S.  Commissioner  of  Education  for  1903-04.  This,  again,  is 
one  of  the  factors  which  receives  consideration  in  Dr.  Edward  L.  Thorn- 
dike's  publication  on  "The  Elimination  of  Pupils  from  School,"  pub- 
lished by  the  U.  S.  Bureau  of  Education  as  Bulletin  No.  4,  1907.  The 
tentative  considerations  foimd  in  the  report  of  the  Commissioner  of 
Education  of  the  State  of  New  York  for  1908,  in  connection  with  his 
discussion  of  industrial  education,  will  receive  further  elaboration  in  the 
report  now  in  preparation.  Perhaps  the  most  useful  source  of  informa- 
tion is  the  "  Psychological  Clinic,"  founded  by  Dr.  Lightner  Witmer,  of 
the  University  of  Pennsylvania,  now  in  its  second  volume.  It  not  only 
contains  individual  studies  of  abnormal  children,  but  also  several  im- 
portant essays  on  the  extent,  not  only  of  abnormality,  but  also  of  that 
lesser  degree  of  mal-adjustment  to  which  the  term  "retardation"  is 
applied  in  various  school  systems.  Attention  is  especially  called  to 
studies  of  conditions  in  Wilmington  and  Camden  by  the  superintendents 
of  schools  in  each  of  these  cities,  and  to  more  comprehensive  articles  on 
"The  Retardation  of  the  Pupils  of  Five  City  School  Systems,"  by  Dr. 
O.  P.  Cornman;  and  "Some  Further  Considerations  upon  the  Retarda- 
tion of  the  Pupils  of  Five  City  School  Systems,"  by  Dr.  R.  P.  Falkner, 
in  which  the  conclusions  of  Dr.  Cornman  are  in  part  corrected  and  in 
large  measure  expanded. 

In  all  of  the  foregoing  no  doubt  has  been  cast  upon  the  validity  of 
the  basal  argument  that  physical  defects  have  a  great  and  important 
influence  on  school  progress.  Public  discussion  has  brought  this  matter 
into  great  prominence  during  recent  years.  The  ph3'sical  examinations 
that  have  been  made  have  demonstrated  that  many  children  have  not 
the  healthy  bodies  that  we  have  been  taught  to  believe  are  the  necessary 
accompaniments  of  sound  minds.  It  is  certainly  disquieting  to  read  that 
two-thirds  of  the  school  children  of  New  York  City  have  physical  defects, 
and  the  inference  has  frequently  been  drawn  that  we  have  in  this  fact 
the  explanation  of  backwardness  in  our  schools.  To  be  exact,  we  have 
one  cause,  not  the  cause.  Among  other  factors  must  be  reckoned,  for 
example,  late  entrance,  irregular  attendance,  mental  dullness,  transfers, 
ignorance  of  the  English  language,  the  "lockstep"  in  promotions. 


Retardation  and  Physical  Defects  189 

To  what  extent  do  physical  defects  cause  backwardness?  We  do 
not  know.  We  do  know  that  we  have  here  a  fruitful  field  for  investiga- 
tion. Such  limited  studies  as  have  so  far  been  made  to  ascertain  the 
quantitative  relationship  between  physical  defects  and  backwardness 
have  shown  a  much  smaller  causal  relation  than  has  been  assumed  and 
proclaimed  by  those  advocating  the  physical  examination  of  school 
children.  Some  of  the  best  work  that  has  been  done  on  this  problem 
is  that  of  Dr.  Walter  S.  Cornell,  of  the  Medical  Department  of  the  Uni- 
versity of  Pennsylvania.  The  results  of  some  of  his  investigations  were 
published  in  an  article  in  the  "Psychological  Clinic"  of  January  15, 
1908.  Among  219  children  of  both  sexes  from  six  to  twelve  years  old 
in  one  school  in  Philadelphia,  he  found  the  following  results: 

Average  Per  Cent. 
IN  Studies. 

Normal  children 75 

Average  children 74 

General  defectives 72.6 

Children  having  adenoids  and  enlarged  tonsils 72 

In  another  investigation  the  children  of  five  schools  were  examined 
for  physical  defects.  They  were  divided  into  so-called  "exempt" 
children,  or  those  whose  work  had  been  so  thoroughly  satisfactory  that 
they  were  advanced  to  higher  grades  without  examination,  and  "non- 
exempt,"  or  those  whose  work  was  less  satisfactory.  The  following 
were  the  results: 

Exempt.  Non-Exempt. 

Children  examined 907  687 

Per  cent,  defective 28.8  38.1 

Still  another  examination  was  conducted  in  one  school  to  determine, 
if  possible,  the  degree  of  harmful  influence  of  defects  of  the  nose  and 
throat.     The  results  follow: 

Bright  Ddll  Dullest 

Children.  Children.  Children. 

Number  examined J .  89  32  29 

Having  nose  or  throat  defects.  .10  9  9 

Percent 11. i  28.1  31 

In  an  article  published  in  the  New  York  Medical  Journal  of  June  i, 
1907,  Dr.  Cornell  gives  some  results  of  a  study  of  the  effect  of  eyestrain 


190  Medical  Inspection  of  Schools 

on  school  progress.  In  this  investigation  the  relationship  of  poor 
vision  to  scholarship  was  studied  in  219  children.  The  results  are 
expressed  in  the  percentages  obtained  by  the  children  in  arithmetic, 
geography,  and  spelling. 

Children  With:        Arithme-  Geography.  Spelling.  Average. 

TIC. 

Normal  vision 79  69  76  75 — 

Fair  vision 70  71  77  73  + 

Bad  vision 66  70      -  71  69 

It  is,  of  course,  to  be  noted  that  these  investigations  were  conducted 
with  a  comparatively  small  number  of  cases.  Moreover,  the  results  ob- 
tained above  represent  only  a  very  small  part  of  the  careful  and  pains- 
taking studies  conducted  by  Dr.  Cornell.  The  conclusion  that  he 
draws  from  his  studies  is  that  the  educational  result  in  our  public  schools 
suffers  a  discount  of  about  6  per  cent,  in  the  case  of  the  physically 
defective  children,  as  well  as  a  waste  of  time  rightfully  belonging  to  the 
normal  children. 

During  the  school  years  1904-5  and  1905-6  very  extensive  investiga- 
tions have  been  conducted  in  the  city  of  Camden,  N.  J.,  by  Superintendent 
of  Schools  James  E.  Bryan.  The  results  are  reported  at  length  in  the 
annual  report  of  the  Board  of  Education  of  the  city  of  Camden,  N.  J., 
for  the  year  ending  June  30,  1906.  In  all,  10,130  children  of  both 
sexes  were  examined.  From  these  were  selected  2,020  children  of 
excessive  age  for  their  respective  grades,  counting  as  of  excessive  age 
those  who  were  at  least  one  year  more  behind  their  grades  than  the 
standards  commonly  used  in  similar  discussions.  A  careful  attempt 
was  made  to  classify  the  causes  for  the  backwardness  of  these  2,020 
pupils  in  their  school  studies.  The  causes  assigned  in  the  classification 
were: 

1.  Age  upon  starting  in  school, 

2.  Absence, 

3.  Slowness, 

4.  Dullness, 

5.  Health, 

6.  Physical  defects  other  than  sight  and  hearing, 

7.  Mental  weakness. 

Under  these  seven  reasons  for  excessive  age  the  2,020  children  were 
distributed  as  is  shown  in  the  following  table : 


Retardation  and  Physical  Defects 

Excessive  age  due  to: 


191 


Defects 

Number 

Ex- 
amined. 

Age  Upon 
Starting. 

Absence. 

Slow- 
ness. 

Dull- 
ness. 

Health. 

Other 

than 
Sight  and 
Hearing. 

Mental 
Weak- 
ness. 

Per  Cent. 

Per  Cent. 

Per  Cent. 

Per  Cent. 

Pel  Cent. 

Per  Cent. 

Per  Cent. 

Boys . . . 

1081 

20.2 

29.4 

19.8 

12. 1 

7-4 

3-6 

4.6 

Girls... 

939 

22.4 

27-5 

22.4 

11.9 

12. 1 

4.4 

2.6 

Total 

2020 

21.2 

28.5 

21 

12 

9.6 

3-9 

3-7 

Whether  the  causes  assigned  have  sufficient  definiteness,  or  whether 
the  underlying  assumption  that  in  each  case  there  is  a  single  cause 
be  correct,  need  not  be  considered  here.  For  the  purposes  of  the  present 
discussion,  two  points  in  regard  to  this  table  are  significant:  First, 
that  the  results  of  the  Camden  investigation  decidedly  support  the  con- 
tention that  physical  defects  constitute  a  cause,  but  not  the  cause  of 
retardation;  secondly,  that  the  bearing  of  physical  defectiveness  on 
school  backwardness  does  not  appear  to  be  very  great.  Under  the 
caption  "Health"  it  appears  that  bad  health  was  assigned  as  a  reason 
for  backwardness  in  7.4  per  cent,  of  the  cases  of  the  boys  and  in  12.1 
per  cent,  of  those  of  the  girls.  Physical  defects  other  than  sight  and 
hearing  were  assigned  as  reasons  for  excessive  age  in  3.6  per  cent,  of 
the  cases  of  the  boys  and  4.4  per  cent,  of  those  of  the  girls. 

The  foregoing  illustrations,  while  they  point  in  the  same  direction, 
namely,  that  physical  defect  is  only  one  cause  of  backwardness,  and 
perhaps  not  so  prominent  as  has  frequently  been  assumed,  show  at  the 
same  time  the  paucity  of  the  data  directly  bearing  on  these  points. 

In  view  of  this  scarcity  of  data,  attention  may  be  called  to  some 
preliminary  results  of  a  more  comprehensive  investigation  now  in  pro- 
gress, but  still  incomplete.  During  May  and  June  of  1908  the  authors 
of  this  volume  have  conducted  an  investigation  into  some  conditions 
existing  among  children  in  fifteen  schools  of  New  York  City  in  the 
Borough  of  Manhattan.  The  total  membership  of  the  schools  is  some- 
thing over  20,000  and  it  is  almost  equally  divided  among  boys  and  girls. 
The  schools  themselves  are  located  in  different  sections  of  the  city, 
from  the  lower  East  Side  to  the  Bronx.  The  school  records  of  all  of 
these  pupils  have  been  gathered  and  a  careful  study  undertaken  to 
determine,  if  possible,  conditions  bearing  on  the  phenomena  of  retarda- 


192 


Medical  Inspection  of  Schools 


tion.  For  the  purposes  of  the  study,  pupils  have  been  divided  into  two 
groups :  normal  age  and  above  normal  age.  All  pupils  in  the  i  A  grade 
(lower  first)  who  at  the  end  of  the  school  year  are  8^  years  old  or  younger 
are  considered  of  normal  age,  those  older  than  8^  of  above  normal  age. 
In  the  I  B  grade  (upper  first)  9  years  marks  the  limit  of  the  normal  age 
group  and  those  older  are  considered  above  normal  age.  In  the  2  A 
grade  (lower  second)  the  limit  is  9^,  in  the  2  B  (upper  second)  10,  and 
so  on  up  to  16  years  of  age  in  the'8  B  grade  (upper  eighth). 

In  the  endeavor  to^find  out  the  relation  bet\\een  physical  defect 
and  retardation,  the  records  of  all  pupils  who  have  been  examined  by 
the  physicians  of  the  Board  of  Health  have  been  carefully  compiled 
and  studied.  Among  the  20,000  children,  7,608  have  had  physical 
examinations.  As  the  results  of  this  study  are  to  be  fully  presented 
in  a  separate  report,  it  has  been  thought  best  to  give  here  as  original 
data  merely  the  tables  showing  the  distribution  of  these  pupils  by  grades 
and  defects,  and  by  ages  and  defects.  The  derivative  tables  are  all  in 
terms  of  percentages,  in  order  to  render  them  more  clear,  and  the  results 
are  given  by  full  grades  rather  than  by  half  grades  for  the  same  purpose. 
Tables  A  and  B  present  the  original  data. 
TABLE  A.— DISTRIBUTION  OF  PUPILS  BY  GRADES  AND  DEFECTS 


s 

H  "5 

Q    . 

Defec- 

w 6 
>  z 

Defec- 

1.^ 

Other 

Total 

§ 

No. Ex- 

0 ^ 

<< 

tive 

«5 

tive 

«  -yi 

Ade- 

De- 

De- 

« 

amined. 

Vision. 

gw 

Teeth. 

Si 

noids. 

fects. 

fects. 

0 

1^ 

>< 

lA.... 

678 

104 

288 

22 

141 

427 

277 

142 

120 

1,417 

iB.... 

1,151 

175 

503 

39 

290 

749 

454 

293 

191 

2,519- 

2A.... 

951 

102 

364 

159 

252 

660 

359 

275 

194 

2,263 

2B.... 

788 

^3?, 

274 

193 

15s 

416 

253 

164 

108 

1.563 

3A..- 

663 

96 

183 

153 

III 

358 

177 

98 

79 

1,159 

3B-.. 

620 

119 

107 

128 

55 

350 

163 

59 

93 

955 

4A.... 

533 

139 

52 

137 

52 

227 

100 

57 

75 

700 

4B.... 

531 

152 

59 

138 

40 

209 

127 

71 

81 

725 

5A..- 

338 

"5 

48 

86 

29 

lOI 

65 

28 

22 

379 

5B.... 

299 

122 

5 

72 

13 

97 

41 

15 

14 

257 

6A.... 

314 

122 

11 

84 

48 

91 

38 

10 

31 

313 

6B.... 

167 

55 

7 

34 

12 

64 

25 

II 

13 

166 

7A.... 

212 

55 

8 

56 

31 

76 

24 

16 

28 

239 

7B.... 

159 

69 

12 

44 

12 

17 

30 

3 

17 

135 

8A.... 

134 

27 

II 

38 

8 

64 

II 

4 

15 

151 

8B.... 

70 

19 

7 

28 

3 

7 

15 

2 

5 

67 

7,608 

1,604 

1.939 

1,411 

1,252 

3,913 

2,159 

1,248 

1,086 

13,008 

Retardation  and  Physical  Defects 


193 


TABLE  B.— DISTRIBUTION  OF  PUPILS  BY  AGES  AND  DEFECTS 


Q    . 

0  a 

Defec- 

li 

Defec- 

Q 
Id 

Other 

Total 

Ages. 

No.  Ex- 

Sg 

»  z 

tive 

^i 

tive 

HZ 

Ade- 

De- 

De- 

amined. 

5^ 

Vision. 

S2 

Teeth. 

«  0 

fects. 

fects. 

s---- 

9 

2 

6 

4 

4 

1 

I 

2 

18 

6 

586 

100 

231 

24 

124 

37^ 

235 

T-ZS 

105 

1,232 

7.... 

1,286 

173 

53f 

81 

321 

850 

508 

322 

210 

2,828 

8.... 

i>i97 

169 

427 

210 

241 

728 

439 

259 

188 

2,492 

9 

1,019 

i«5 

286 

206 

166 

567 

290 

x88 

136 

1.839 

10 

911 

202 

178 

228 

118 

453 

209 

124 

127 

1.437 

II 

«S9 

219 

132 

201 

103 

355 

177 

98 

109 

1. 175 

12 

663 

199 

65 

176 

70 

222 

128 

5« 

«7 

806 

13.... 

510 

163 

35 

121 

50 

182 

84 

li 

67 

572 

14 

393 

125 

26 

109 

37 

112 

60 

23 

37 

404 

15.... 

144 

53 

10 

37 

13 

45 

21 

5 

10 

141 

16.... 

42 

12 

5 

15 

4 

IS 

7 

I 

6 

53 

17.... 

7 

2 

I 

2 

I 

2 

-. 

I 

2 

9 

18 

2 

I 

I 

.. 

-■ 

-- 

-- 

-- 

2 

7,608 

1,604 

i>939 

1,411 

1,252 

3.913 

2,159 

1,248 

1,086 

13,008 

Among  the  7,608  pupils,  6,084  fell  within  the  normal  age  group  and 
1,524  in  the  above  normal  age  group.  The  following  table  shows  the 
percentage  of  physically  defective  pupils  in  each  group  by  grades : 

Normal  Age.  Abo\'e  Normal  Age. 

Grade,  Per  cent.  Per  cent. 

defective.  defective. 

1 85  81.3 

2 86.8  84.5 

3 832  83.3 

4 71-6  74-7 

5 63.8  60.2 

6 63.8  61.7 

7 68.2  60.2 

8 771  75 

Total 79.8  74.9 

Of  course,  the  immediately  striking  feature  of  this  table  is  that 
nearly  80  per  cent,  of  the  normal  age  children  are  found  to  have  physical 
defects,  while  only  about  75  per  cent,  of  the  above  normal  age  children 
are  defective.  This  feature  was  an  unlocked  for  surprise  to  the  inves- 
tigators. 

The  second  noteworthy  point  is  that  the  percentage  of  defective 
children  in  the  lower  grades  is  decidedly  greater  than  in  the  upper 
grades.  It  is  to  be  remarked,  too,  that  the  percentage  of  defectives 
13 


194  Medical  Inspection  of  Schools 

in  the  first  grade  would  have  been  decidedly  greater  than  that  in  the 
second  grade  had  it  not  been  for  the  fact  that  practically  no  children 
are  tested  for  defective  eyesight  in  the  first  grade,  thereby  decidedly 
reducing  the  percentage  of  defectiveness.  It  is  likewise  true  that  the 
seventh  and  eighth  grades  show  a  much  higher  per  cent,  than  would 
normally  be  the  case.  This  is  due  to  the  facts  that  the  figures  for  the 
seventh  and  eighth  grades  are  almost  exclusively  for  one  school  having 
a  high  percentage  of  defectives,  and  for  comparatively  small  numbers 
of  cases.  The  reason  for  this  is  that  in  most  schools  no  physical  ex- 
aminations were  made  in  the  upper  grades. 

Our  investigations  lead  us  to  believe  that  under  normal  conditions 
physical  examinations  as  now  conducted  in  New  York  City  would 
show — if  the  eyesight  of  children  in  the  first  grade  could  be  tested — a 
percentage  of  defectives  of  about  90  in  the  first  grade  and  that  this  per 
cent,  would  gradually  reduce  through  the  grades  to  about  50  in  the 
eighth. 

A  computation  of  the  average  number  of  defects  per  child  in  the 
normal  age  and  above  normal  age  groups  gives  results  not  dissimilar 
from  those  discussed. 

AVERAGE  NUMBER  OF  DEFECTS  PER  DEFECTIVE  CHILD 
Gkade.                                                                  Normal  Age.  Above  Normal  Age. 

1 2.5  2.3 

2 2.5  2.6 

3 1-9  2.1 

4 1.8  1.8 

5 i-S  1.6 

6 1-5  1-5 

7 i-S  i-S 

8 1.3  1.6 

Total 2.1  2.0 

Here  again  we  are  confronted  by  the  same  phenomena  of  more 
defects  among  the  children  of  normal  age  than  among  those  of  above 
normal  age,  and  of  the  reduction  in  the  number  of  defects  from  the 
first  grade  to  the  eighth.  Of  course,  a  question  which  immediately 
presents  itself  is  whether  this  unlooked  for  discrepancy  between  the  nimi- 
ber  of  defects  among  normal  age  children  and  the  number  among  those 
of  more  than  normal  age  is  to  be  accoimted  for  by  a  consistent  pre- 
ponderance of  each  separate  kind  of  defect  among  the  normal  age  chil- 
dren, or  whether  some  sorts  of  defects  are  more  prevalent  among  those 


Retardation  and  Physical  Defects 


195 


of  normal  age  and  others  among  those  of  greater  than  normal  age. 
Light  is  shed  on  this  problem  by  the  following  table: 

PER  CENT.  HAVING  EACH  DEFECT  BY  DEFECTS 

KoEMAL  Age.  Above  Norjiax.  Ace. 

Examined 100  100 

Defective 79.9  74-8 

Enlarged  glands 26.9  19.5 

Defective  vision 23.5  26.9 

Defective  breathing 16.7  15.2 

Defective  teeth 53.3  43.8 

Hypertrophied  tonsils 29.9  22.0 

Adenoids 17. i  13.4 

Other  defects i4-i  i4-9 


Here  we  see  that  each  separate  sort  of  defect  is  found  more  frequently 
among  children  of  normal  age  than  among  those  of  greater  than  nor- 
mal age,  with  t^'o  exceptions.  These  are  vision  and  "other  defects." 
The  difference  in  regard  to  vision  is  striking.  Whereas  in  the  case  of 
the  other  defects  there  is  considerable  preponderance  among  the  normal 
age  pupils,  in  the  case  of  vision  only  23.5  per  cent,  are  found  to  be  defec- 
tive in  the  normal  age  group,  while  26.9  of  those  in  the  above  normal  age 
group  have  defective  vision.  This  at  once  leads  to  the  stispicion  that 
in  its  relation  to  retardation,  vision  does  not  follow  the  same  rules  as  do 
other  forms  of  defects. 

Having  discovered  that  the  same  rules  do  not  uniformly  apply 
to  all  of  the  several  sorts  of  defects,  it  becomes  worth  while  to  study 
each  defect  separately  by  grades  and  ages.  The  following  table  pre- 
sents the  per  cent,  of  those  of  each  individual  age  suffering  from  each 
defect. 

PER  CENT.  HAVING  EACH  DEFECT  BY  AGES 


Ages. 


6 

7 
8 

9 
10 
II 
12 

13 
14 
15 


Defec- 
tive. 


82.9 
86.5 
85.8 
81.8 
77.8 

73-8 
69.9 
68.0 
68.1 
63.1 


En- 
larged 
Glands 


39-4 
41.6 

35-6 
28.0 

19-5 
15-7 
9.8 
6.8 
6.6 
6.9 


Defec- 

TI\'X 

Vision. 


17s 
20.2 
25.0 

23-9 
26.5 

23-7 
27.7 
25.6 


Defec- 
tive 
Breath- 
ing. 


21. 1 

24.9 

20.1 

16.2 

12.9 

12.2 

10.5 

9.8 

9.4 

9.0 


Defec- 
tive 
Teeth. 


645 
66.0 
60.8 
55-6 
49-7 
42-3 
33-4 
35-6 
28.4 
31.2 


Hyper- 
tro- 
phied 
Tonsils, 


40.1 

39-5 
36.6 
28.4 
22.9 
21.0 

193 
16.4 

15-2 

145 


Ade- 
noids. 


23.0 

25.0 

21.6 

18.4 

13.6 

11.6 

8.7 

6.4 

5-8 

3-4 


Other 
De- 
fects. 


17.9 
16.3 
iS-7 
133 
139 
12.9 

131 

131 

9.4 

6.9 


196  Medical  Inspection  of  Schools 

A  study  of  the  table  reveals  additional  characteristics  of  the  several 
sorts  of  defect.  For  instance,  under  enlarged  glands  we  note  that  the 
percentage  steadily  falls  from  about  40  among  six  and  seven  year  old 
children  to  something  over  6  among  thirteen  and  fourteen  year  old 
children.  In  the  case  of  vision,  on  the  other  hand,  it  increases  from 
17  per  cent,  among  eight  year  old  children  to  25  per  cent,  among  fifteen 
year  old  children.  The  percentage  of  defective  breathing,  again, 
decreases  somewhat  as  does  that  of  enlarged  glands,  falling  from  about 
25  per  cent,  among  seven  year  old  children  to  9  among  fifteen  year  old 
children.  A  similar  steady  decrease  is  found  in  the  case  of  defective 
teeth,  where  the  percentage  falls  from  66  among  seven  year  old  children 
to  31  among  fifteen  year  old  children.  A  like  condition  is  found  in  the 
case  of  hypertrophied  tonsils.  In  the  case  of  adenoids  the  phenomenon 
is  even  more  marked,  the  percentage  falling  from  25  among  seven  year 
old  children  to  3.4  among  those  fifteen  years  old.  A  steady,  although 
not  nearly  so  rapid  fall,  is  also  found  in  the  case  of  other  defects. 

In  compiling  this  table,  data  for  the  ages  of  five,  sixteen,  seventeen, 
and  eighteen  years  have  been  omitted,  for  the  reason  that  the  number 
of  cases  vmder  each  of  these  ages  is  so  small  as  to  render  them  insignifi- 
cant. Percentages  of  defective  vision  at  the  ages  of  six  and  seven  are 
not  given  because  pupils  at  those  ages  are  almost  without  exception 
in  the  first  grades,  and  as  they  cannot  write,  they  are  not  tested  for 
defective  vision.  In  all  of  these  cases  attention  mtist  be  called  to  the 
fact  that  the  decrease  in  the  per  cent,  of  defective  children  is  not  due 
to  the  falling  out  or  leaving  school  of  the  children  suffering  from  these 
defects.  This  might  be  put  forward  as  an  explanation  if  we  had  to  do 
with  children  above  the  age  of  compulsory  attendance,  or  if  the  charac- 
teristic decrease  did  not  take  place  until  the  age  of  fourteen  or  fifteen; 
but  such  is  not  the  case.  We  have  to  do  with  children  of  from  six  to 
fifteen  years  of  age,  and  the  marked  decrease  begins  among  the  eight, 
nine,  and  ten  year  old  children,  and  continues  steadily. 

As  the  older  children  in  general  are  found  in  the  upper  grades  and 
the  younger  children  in  the  lower  grades,  it  is  certainly  to  be  expected 
that  a  tabulation  of  defects  by  grades  will  show  the  same  characteristic 
reductions,  and  the  same  exception  in  the  case  of  vision.  This  expecta- 
tion is  realized  in  the  tabulations  made. 


Retardation  and  Physical  Defects  197 

PER  CENT.  DEFECTIVE  BY  DEFECTS  AND  WHOLE  GRADES 


Grades. 

Enlarged 
Glands. 

Defective 
Vision. 

Defective 
Breathing. 

Defective 
Teeth. 

Hypertro- 

PHIED 

Tonsils. 

Adenoids. 

I 

2 

3 

4 

5 

6 

7 

8 

43-2 

36.6 

22.6 

10.4 

8.3 

3-7 

5-4 

8.8 

20.2 
21.9 
25.8 
24.8 

24-5 

26.9 
32-3 

23-5 

23-4 

12.9 

8.6 

6.5 
12.4 

5-3 

64.2 
61.8 

55-1 
40.9 
31.0 
32.2 
25.0 
34-8 

39-9 
351 
26.5 
21.3 
16.6 
13.0 

14-5 
12.8 

237 

25.2 

12.2 

12.0 

6.7 

4-3 

5-1 

2.9 

Apart  from  the  fact  that  the  eighth  grade,  for  reasons  already  stated, 
cannot  be  considered  as  representative,  the  table  presents  many  analo- 
gies with  the  preceding.  The  percentage  of  defects  dwindles  as  the 
grades  advance,  though  here  again  vision  stands  in  a  class  by  itself, 
increasing  rather  steadily  with  the  higher  grades. 

The  foregoing  tables  have  shown  clearly  the  fact  that  age  is  the 
important  factor  in  considerations  having  to  do  with  the  percentage 
of  physically  defective  school  children.  It  is  evident  that  it  is  not 
enough  to  say  merely  that  in  a  given  city  66  per  cent,  of  the  pupils  are 
foimd  to  be  physically  defective  to  a  greater  or  less  extent.  We  need 
to  know  the  percentage  of  defectiveness  for  each  separate  defect  and 
something  of  the  age  of  the  children.  It  is  evident  that  if  vision  were 
omitted,  the  general  percentage  of  defectiveness  might  be  expected  to 
be  great  if  examinations  were  conducted  among  the  lower  grades,  and 
comparatively  small  if  they  were  conducted  among  the  upper  grades. 

The  same  would,  of  course,  be  true  if  the  results  were  tabulated 
by  ages  rather  than  by  grades.  For  instance,  in  the  investigation  in 
point  a  computation  was  made  to  find  the  number  of  defects  per  himdred 
children  in  each  grade,  omitting  vision  and  defective  teeth,  and  basing 
the  calculation  solely  on  cases  of  enlarged  glands,  defective  breathing, 
hypertrophied  tonsils,  and  adenoids.  The  computation  resulted  as 
follows : 


Grades 


Defects  per 

100 

Children. 

130 

120 

....    74 
....    52 


Grades. 

5--- 
6... 


Defects  per 
100 
Children. 


38 
35 
36 
29 


198  Medical  Inspection  of  Schools 

The  same  striking  falling  off  is  shown  if  a  similar  computation  is 
made  by  ages,  instead  of  by  grades. 

Defects  per  Defects  per 

Grades.  100  Grades.  100 

Children.  Children. 

6 123  II 68 

7 131  12 47 

8 114  13 39 

9 91  14 24 

10 69 

It  is  entirely  probable  that  had  the  results  of  the  physical  examina- 
tions performed  in  the  schools  by  the  physicians  of  the  Board  of  Health 
of  New  York  City  taken  into  account  age  and  grade,  the  announced 
results  and  conclusions  would  have  been  very  different.  Reports  on 
the  examinations  of  more  than  100,000  school  children  have  been  pub- 
lished and  the  per  cent,  of  defectives  has  run  from  66  to  72.  From 
these  results  it  has  been  argued  that  as  there  was  no  reason  to  believe 
that  these  were  exceptional  children,  it  might  fairly  be  concluded  that 
they  were  typical  of  school  children  in  New  York  and  even  of  children 
throughout  the  United  States.  On  this  hypothesis  calculations  have 
been  based,  showing  the  probable  number  of  children  in  the  United 
States  in  need  of  medical,  surgical,  or  dental  attention,  and  of  the 
probable  number  of  cases  of  enlarged  glands,  defective  eyesight,  poor 
teeth,  adenoids,  etc.,  existing  among  them.  Now,  it  must  be  remembered 
that  the  examinations  performed  in  New  York  have  very  largely  been 
among  the  very  yovmg  children  in  the  first  and  second  grades.  As 
these  children  represent  a  larger  proportion  of  defectives  and  very  much 
greater  percentages  of  those  suffering  from  such  defects  as  enlarged 
glands,  hj'pertrophied  tonsils,  and  adenoids,  it  is  at  once  evident  that 
they  are  not  only  not  representative  of  children  in  the  United  States, 
but  not  even  of  children  in  New  York  or  in  ManhattanA  They  are 
representative  only  of  very  yoimg  school  children  in  Manhattan,  and 
it  is,  to  say  the  least,  dangerous  to  argue  anything  concerning  the  number 
of  children  in  the  United  States  having  each  of  the  different  sorts  of 
defects  from  data  published  so  far  by  the  New  York  Board  of  Health. 

Another  question  which  so  far  has  had  little  attention  is  that  of  the 
relation  of  sex  and  physical  defects.  The  tabulation  of  the  percen- 
tages of  defectiveness  by  sexes  for  each  kind  of  defect  gives  the  following 
results: 


Retardation  and  Physical  Defects  199 

PER  CENT  HAVING  EACH  DEFECT  BY  SEXES 

Boys.  Girls. 

Defective 78.5  79.2 

Enlarged  glands 32.2  20.3 

Defective  vision 15.7  20.8 

Defective  breathing 19. i  14.3 

Defective  teeth 48.4  53.5 

Hypertrophied  tonsils 33.1  24.7 

Adenoids 17.4  15.6 

Other  defects 13.6  14.7 

DEFECTS  PER  CHILD 

Boys.  Girls. 

1.8  1.6 

Here  again  we  have  some  surprising  variations;  32.2  per  cent, 
of  the  boys  are  siiffering  from  enlarged  glands,  while  we  found  only 
20.3  in  the  case  of  the  girls.  Again,  vmder  defective  breathing  we  have 
19. 1  per  cent,  for  the  boys  and  14.3  per  cent,  for  the  girls;  while  hyper- 
trophied tonsils  are  present  in  33.1  per  cent,  of  the  cases  among  the 
boys  and  only  24.7  per  cent,  among  the  girls.  On  the  other  hand, 
the  boys  outstrip  their  sisters  in  regard  to  vision  and  teeth.  These 
results  are  derived  from  the  examination  of  a  comparatively  large 
number  of  cases,  the  boys  numbering  3,301  and  the  girls  4,305. 

The  results  that  have  been  discussed,  showing  so  consistently  as 
they  do  that  retarded  or  above  normal  age  pupils  have  fewer  defects 
than  do  those  of  normal  age,  furnish  food  for  careful  thought.  Were 
further  data  not  available,  it  would  certainly  be  difl&cult  to  explain  the 
seeming  anomaly,  but  the  data  showing  the  percentage  of  defectives 
by  ages  and  grades  are  illuminating.  We  see  at  once  that  age  is  the 
important  factor.  With  the  exception  of  vision,  the  percentage  of 
pupils  found  to  be  suffering  from  each  separate  sort  of  defect  decreases 
rapidly  as  age  increases.  Naturally,  similar  conditions  are  found  when 
children  of  upper  grades  are  compared  with  those  of  lower  grades. 

It  is  evident  that  we  have  here  a  field  for  many  fvirther  interesting  and 
important  investigations.  Without  entering  into  any  one  of  them, 
however,  we  are  confronted  by  one  consideration  of  prime  importance, 
which  is  that  defects  decrease  with  age. 

The  importance  of  this  on  all  investigations  into  the  influence  of 
physical  defects  on  school  progress  is  at  once  evident.  WTiether  the 
term  "retarded"  is  used  to  express  a  condition  or  an  explanation,  it 


200  Medical  Inspection  of  Schools 

will  always  follow  from  the  definition  itself  that  retarded  children  will 
be  older  than  their  fellow-pupils  in  the  same  grades.  This  condition 
will  exist,  whether  time  in  grade  or  an  arbitrary  age  dividing-line  be 
taken  as  the  criterion  for  separating  pupils  into  "retarded"  and  "not 
retarded,"  or  "normal  age"  and  "above  normal  age"  groups.  In  any 
case  it  will  always  be  true  that  the  "backward  pupils"  will  be  the  older 
pupils. 

Now,  the  older  pupils  are  found  to  have  fewer  defects.  This  is  true, 
whether  they  are  behind  their  grades  or  well  up  in  their  studies.  There- 
fore, it  is  not  surprising  that  we  find  that  80  per  cent,  of  all  children  of 
normal  age  have  physical  defects  more  or  less  serious,  while  only  75 
per  cent,  of  those  of  above  normal  age  are  found  to  be  defective.  This 
does  not  mean  that  pupils  with  more  physical  defects  are  brighter 
mentally.  It  simply  means  that  those  who  are  above  normal  age  are 
older,  and  that  older  pupils  have  fewer  defects. 

Why  this  should  be  so  it  is  not  easy  to  explain.  It  is  probable 
that  we  have  here  a  condition  brought  about  by  a  number  of  influencing 
factors.  In  the  first  place,  it  must  be  remembered  that  the  higher 
grades  are  to  a  certain  extent  made  up  of  the  survivors  of  the  more  fit. 
Those  who  reach  the  higher  grades  are  at  least  to  some  extent  made  up 
of  the  brighter,  the  more  ambitious,  the  more  physically  fit,  those  of 
higher  social  standing,  and  those  whose  parents  are  in  better  economic 
circumstances.  If  the  child  whose  physical  defects  and  mental  dullness 
render  him  exceedingly  slow  in  his  school  studies  leaves  school  at  the 
earliest  possible  moment  permitted  by  the  compulsory  education  laws, 
or  even  anticipates  that  moment,  he  naturally  is  not  present  to  be  counted 
among  the  older  children  or  those  in  the  higher  grades.  This  factor, 
while  undoubtedly  operative,  is  probably  not  one  of  comparatively 
great  importance. 

A  second  consideration,  and  one  of  probably  far  greater  weight,  is 
that  children  do  actually  outgrow  their  defects.  No  other  conclusion 
seems  possible  as  an  explanation  of  such  great  falling  off  as  we  have  in 
the  case  of  enlarged  glands,  with  which  40  per  cent,  of  the  six  year  old 
children  suffer,  but  which  are  found  present  in  only  12  per  cent,  of  the 
sixteen  year  old  ones;  or  in  that  of  defective  breathing,  where  the 
reduction  is  from  21  to  10  per  cent.;  or  in  that  of  adenoids,  with  a  fall 
from  23  to  a  little  over  2  in  the  same  years.     Even  in  the  case  of  defective 


Retardation  and  Physical  Defects  201 

teeth  it  is  found  that  nearly  65  per  cent,  of  the  six  year  old  children  are 
included  among  those  needing  attention,  and  only  35  per  cent,  of  the 
sixteen  year  old  ones.  Of  course,  in  this  connection  it  must  be  remem- 
bered that  the  older  children  have  their  permanent  teeth,  and  imdoubtedly 
too  a  much  larger  proportion  of  them  have  received  dental  attention. 

In  studying  the  problems  of  school  progress  and  physical  defects, 
we  must  not  forget  that  school  success  is  to  only  a  Hmited  extent  a  true 
measiure  of  real  ability.  It  may  often  be  rather  an  indication  of  adapta- 
bility and  docility.  Indeed,  it  would  not  be  surprising  to  find  that  the 
child  of  perfect  physical  soundness  and  exuberant  health  had  so  many 
outside  interests  as  to  render  him  not  particularly  successful  in  school 
work,  and  that  he  found  the  rigid  discipline  of  the  schoolroom  so  irk- 
some as  to  cause  him  to  fail  of  approbation  by  his  teachers. 

It  is,  of  course,  obvious  that  this  whole  subject  of  the  relation  of 
physical  defects  to  school  progress  is  one  of  great  importance  and  one 
which  will  require  a  great  deal  of  painstaking  investigation  and  careful 
study.  Nevertheless,  from  the  brief  data  here  presented  a  few  conclu- 
sions of  value  may  be  drawn.     Among  them  are  the  following: 

(i)  Successful  medical  inspection  results  in  indirect, 
not  direct,  financial  economies. 

(2)  It  does  have  an  effect  on  the  problem  of  retardation, 
but  does  not  affect  accommodation  and  "half  time." 

(3)  Since  our  investigation  shows  that  defects  decrease 
with  age,  statistics  dealing  with  physical  defects  among 
school  children  are  not  significant  unless  they  are  presented 
in  terms  of  grades  and  ages.  Most  defects  decrease  with 
age,  and  backward  or  retarded  children  have  fewer  defects 
than  those  of  normal  age  because  they  are  older. 

(4)  Physical  defects  constitute  a  cause,  not  the  cause,  of 
retardation. 

The  foregoing  conclusions  —  so  different  from  those  which  have 
been  emphasized  in  current  discussion — must  be  briefly  examined  with 
respect  to  their  significance  for  the  general  problem  of  medical  inspection. 

Ovu:  first  conclusion  is  that  successful  medical  inspection  results 
in  indirect,  not  direct,  financial  economies.  There  is  an  economy 
which   means    the   abstention    from    expenditure.     There   is    another 


202  Medical  Inspection  of  Schools 

economy  which  means  the  production  of  greater  eflficiency.  The 
economies  effected  by  medical  inspection  are  of  this  second  or  indirect 
sort.  While  they  cannot  be  measured  in  dollars  and  cents,  they  are 
nevertheless  far-reaching  and  important.  Everyone  brings  into  the 
world  a  certain  capital  of  mental  ability  and  physical  soundness.  On 
these  his  value  to  the  state  will  depend  when  he  is  grown.  Any  reason- 
able expenditure  which  will  result  in  their  enhancement  is  in  the  end  an 
economical  expenditure  of  public  funds  to  promote  the  public  welfare. 

Our  second  conclusion  is  that  physical  defects  are  related  to  the 
problem  of  retardation,  but  not  to  that  of  accommodation.  Measured 
in  terms  of  school  progress,  we  naturally  expect  the  sound  and  healthy 
child  to  advance  further  than  the  physically  defective  one.  We  must 
face  the  fact  that  the  school  period  is  brief  and  that  its  effectiveness 
largely  depends  upon  how  far  the  child  advances.  Indeed,  in  the  vast 
majority  of  cases  it  depends  upon  how  far  the  child  advances  by  the 
time  he  reaches  the  age  of  fourteen.  Our  studies  of  the  problem  of 
retardation  lead  us  to  the  conclusion  that  the  greatest  factor  affecting 
the  problem  of  the  child's  progress  through  the  grades  is  that  of  regular 
and  continuous  attendance.  Any  influence  which  tends  to  reduce 
absence  results  in  an  increased  use  of  school  facilities,  and  so  in  greater 
economy,  a  higher  degree  of  efficiency,  and  better  results,  as  measured 
by  educational  standards  of  progress.  Medical  inspection,  in  banishing 
contagious  diseases  from  the  schools  and  in  preventing  or  removing 
physical  defects,  has  a  large  and  important  influence  in  bringing  about 
this  greatly  to  be  desired  result. 

Conclusions  three  and  four  have  to  do  with  the  statistical  aspects 
of  the  problem.  The  evidence  of  cmrent  statistics  on  the  need  for 
physical  inspection  is  twofold.  It  proves  that  physical  defect  is  wide- 
spread. It  enforces  thereby  the  conclusion  that  there  would  be  a  gain 
in  many  respects  by  the  elimination  of  such  defects  as  are  capable  of 
prevention  or  removal  by  medical  science. 

On  the  other  hand,  current  statistics  do  not  establish  physical 
defects  as  the  cause  of  retardation.  Under  the  broad  definition  of  the 
former  it  embraces,  say  80  per  cent,  of  the  school  population — retarda- 
tion say  20  to  40  per  cent.  Hence  it  is  clear  that  there  must  be  cases 
of  defects  among  the  non-retarded.  If  all  the  retarded  were  defective, 
we  should  have — were  20  per  cent,  retarded — 100  per  cent,  defective; 


Retardation  and  Physical  Defects  203 

and  among  the  non-retarded  75  per  cent  defective.  But  some  of  the 
retarded  are  not  defective.  Their  retardation  is  due  to  other  causes. 
Hence  there  must  be  a  certain  per  cent,  of  physically  normal  children 
among  the  retarded.  All  of  these  facts  tend  to  equalize  the  percentage 
of  defectives  among  the  retarded  and  non-retarded. 

It  must  not  be  inferred  that  physical  defects  exercise  no  influence 
upon  school  progress.  They  undoubtedly  do,  but  we  have  not  yet 
discriminated  among  physical  defects.  We  group  together  all  kinds. 
Some  have  a  direct  bearing,  others  none  at  all.  Defective  hearing 
imdoubtedly  exercises  an  important  influence  on  a  pupil's  success  in 
school,  but  the  fact  that  a  child  has  a  club-foot  has  no  such  significance. 
That  we  are  imable  to  measiure  by  statistical  methods  the  influence  of 
physical  condition  upon  school  progress  is  far  from  proving  that  such 
influence  does  not  exist. 

On  the  other  hand,  our  statistical  results  show  most  plainly  that 
medical  inspection  and  school  administration  must  be  more  closely 
related  and  interlocked.  The  medical  inspector  must  have  a  greater 
comprehension  of  school  problems  and  his  work  must  be  adjusted  as  it 
has  not  been  heretofore  if  it  is  to  contribute  to  the  solution  of  these 
problems. 


Bibliography 


REFERENCES 

Allen,  William  H. :    "School  Hygiene."     New  York  Evening  Post, 

Sept.  21,  1907. 
, "A   Broader   Motive   for   School   Hygiene."     Atlantic   Monthly, 

June,  1908. 
"National    Programme    for    Departments    of    School    Hygiene." 

North  American  Review,"  July,  1908. 

J^llport,  Frank :  "  Defective  Eyesight  in  American  Children."     Review 
^  of  Reviews,  June,  1897,  pages  696-9. 

"Tests  for  Defective  Vision  in  School  Children."     Educational 

Review,  New  York,  Sept.,  1897,  pages  150-9. 
"The  Necessity  for  the  Annual  Systematic  Examination  of  School 
Children's  Eyes,  Ears,  Noses  and  Throats,  by  School  Teach- 
ers."    The  Medical  and  Surgical  Monitor,  Feb.,  1904. 
The  Eye  and  Its  Care.     New  York,  1894. 

Arnold,  H.  D. :  "Some  Results  of  the  Medical  Inspection  of  Schools 
in  Boston."  Annals  of  Gynecology  and  Pediatry,  Jan.,  1898, 
Vol.  XL 

Babbitt,  W.  H. :  "Compulsory  Medical  Inspection  of  Schools:  A 
Plea  for  the   Child."     The  Pacific  Commercial  Advertiser, 

Honolulu,  May  12,  1908. 

Baker,    Leigh    K. :     "Medical    Supervision    of    Schools."     Medical 
Gazette,  Cleveland,  Nov.,  1897. 
"Notes  on  the  Examination  of  the  Eyes  of  1048  East  Cleveland,  O., 
School  Children."     Ohio  State  Med.  Jour.,  Feb.,  1907. 

Baker,  S.  Josephine :  "The  Medical  Inspection  and  Examination  of 
School  Children  in  New  York  City."  Annals  of  Gynecology 
and  Pediatry,  19:  441-51. 

Barkhurst,  S.  0.:  "Medical  Inspection  of  Schools  as  a  Factor  in 
Prevention  of  Disease."  Ohio  State  Med.  Jour.,  Feb.  15, 
1907. 

204 


Bibliography  205 

Beyer:  "Observations  on  Normal  Growth  and  Development  under 
Systematized  Exercise."  Report  of  the  Chief  of  the  Bureau 
of  Medicine  and  Surgery  to  the  Secretary  of  the  Navy,  Wash- 
ington, D.  C,  1893,  pages  141-60. 
"The  Influence  of  Exercise  on  Growth."  American  Physical 
Education  Review,  Sept.-Dec,  1896,  pages  76-87. 

Black,  M. :  "The  Physician  in  the  Public  Schools."  Colorado  Med., 
Sept.,  1907. 

Boas,   Franz:    "Anthropological  Investigations  in   Schools."      Ped. 
Sem.,  Vol.  I,  pages  225-8. 
"The    Growth   of    Children."     Science,    Vol.    XIX,    pages    256, 
281-2;  Vol.  XX,  pages  351-2,  and  passim. 

Bowditch,  H.  P. :   "The  Growth  of  Children."     Report  of  the  Board 
of  Health  of  Mass.,  1877,  Vol.  VIII;  1879,  Vol.  X,  pages  33-62; 
1 89 1,  Vol.  XXII,  pages  470-522. 
"Relation  between  Growth  and   Disease."     Transactions   of  the 
Amer.  Med.  Asso.,  1881,  Vol.  XXXII,  pages  376  ff. 

Bromner,  A. :  "  On  the  Importance  of  Examining  the  Eyes  and  Ears 
of  all  the  Children,  not  only  those  of  the  Board  Schools." 
Journal  of  the  Sanitary  Institute,  London,  i;   189-98, 

Browne,  J.  Crichton:    "Education  and  the  Nervous  System."     The 
Book  of  Health,  pages  269  ff. 
Report  on  Overpressure  in  English  Elementaiy  Schools.     London, 
1883. 

Bryan,  James  E. :  "A  Method  for  Determining  the  Extent  and 
Causes  of  Retardation  in  a  City  School  System."  Psych. 
Clinic,  April  15,  1907. 

Burgerstein,  Leo:  "Schulartz."  Rein's  Encyklopadisches  Hand- 
buch  der  Padagogik,  Vol.  \T,  pages  233-56. 

Axel  Key's  Schulhygienische  Untersuchungen.  Page  345.  Ham- 
burg, 1899.  (Resume  of  Key's  investigation  of  the  physical 
conditions  of  Swedish  school  children.) 

"Means  of  Spreading  Hygienic  Knowledge  among  the  People." 
Report  of  the  Com.  of  Ed.  1897-8,  pages  257  ff. 

Burk:  "Growth  of  Children  in  Height  and  Weight."  Amer.  Jour, 
of  Psych.,  April,  1898,  Vol.  IX,  No.  3,  pages  253-326. 

Bumham :    "Bibliography  of  School  Hygiene."     Transactions,  Nat. 
Ed.  Asso.,  1898,  pages  506-23. 
"Health   Inspection   in   the   Schools."     Ped.    Sem.,   April,    1900, 
Vol.  VII,  No.  I,  pages  70  ff. 


2o6  Medical  Inspection  of  Schools 

Burrage  :  "  Medical  Inspection  of  School  Children."  Nat.  Ed.  Asso. 
Jour.,  1898,,  pages  539-44- 

Byrne:  "School  Medical  Inspection  in  Chicago."  Jour,  of  Amer. 
Med.  Asso.,  Nov.  23,  1901. 

Carruth,  F.  W. :  "A  Unique  Municipal  Crusade."  North  Amer. 
Review,  Nov.,  1903,  177:    66-74. 

Chris  man :   "Hearing  of  Children."     Ped.  Sem.,  1892,  Vol.  II,  pages 
391-441. 
"Hearing   of    School    Children."     Northwestern    Monthly,    July, 
1897,  pages  31-35. 

Clark :  "  Physical  Defects  of  Children."  Northwestern  Monthly, 
July,  1897,  pages  24-31. 

Clark,  Hannah  B. :    "Sanitary  Legislation  Affecting  Schools  in  the 

United  States."    Report  of  the  Com.  of  Ed.  1893-4,  Vol.  II, 

pages  1301-49- 
Cohn :    Ueber  die  Notwendigkeit  der  Einfuhrung  von   Schulartzten. 

Page  54.     Leipsic,  1886. 
"Die   Schulartzfrage   in   Breslau."     Zeitschrift   fur   Schulgesund- 

heitspflege,    1898,   No.    11,   pages   579-596;    No.    12,   pages 

643-54- 
"Eyes  and  School  Books."     Pop.  Sci.  Monthly,  XIX,  54. 

Cole,  Harlan  P.:  "The  Prevalence  of  Physical  Defects  in  School 
Children."  Report  of  the  7th  Annual  Conference  of  Sanitary 
Officers  of  the  State  of  New  York,  1907. 

Collins  :   "The  Teeth  of  the  School  Boy."     Nineteenth  Century,  July,  j 
1899. 

Cornell,  Walter  S. :  "Eyestrain  in  School  Children."  New  York 
Med.  Jour.,  June  i,  1907. 

Cronin,  John  J. :   "The  Health  of  New  York  School  Children  from 
the  Point  of  View  of  the  Department  of  Health."     Archives  of 
Pediatrics,  Oct.,  1906. 
4    "The  Doctor  in  the  Public  School."     Review  of  Reviews,  April, 

/  1907,  35;  433-40. 

/         "Physical  Defects  of  School  Children."     Jour,  of  the  New  York 
Institute  of  Stomatology  and  Allied  Societies,  Dec,  1907. 
"School    Children    and    their    Medical    Supervision."     Charities, 
16:  58-62. 

Darlington,  Thomas  :  "The  New  Method  of  Medical  School  Inspec- 
tion."    Jour,  of  the  Med.  Society  of  New  Jersey,  1906. 


Bibliography  207 

Denison :  "The  Advantages  of  Physical  Education  as  a  Prevention  of 
Disease."  Bulletin  of  Amer.  Aca.  of  Med.,  Oct.,  1898,  III, 
No.  9,  page  524. 

Dennett,  W.  S. :  Report  of  the  Examination  of  the  Eyes  of  the  Pupils 
in  the  Schools  of  Hyde  Park.     Hyde  Park,  Mass.,  1880. 

Dowling:    "The  Hygiene  of  the  Ears."     Cincinnati  Lancet-Clinic, 

July,  2,  1898. 
Dukes,  Clement:   "The  Inspection  of  Schools  from  the  Medical  and 

Sanitary  Point  of  View."     Educational  Times,   Dec,   1894, 

pages  505-11. 

Durgin,  S.  H. :  "Medical  Inspection  of  Schools."     Boston. 

Eberhardt,  John  C. :  "Examination  of  the  Eyes  of  School  Children." 
Proceedings,  Nat.  Ed.  Asso.,  1906,  pages  173-7;  Elementary 
School  Teacher,  June,  1907,  7:   263-8. 

Ekeris,  Van  :  "  Notv\-endigkeit,  Aufgabe  irnd  Stellung  der  Schulartzte." 
Sammlung  pad.  Vortrage,  Meyer-Markau,  Vol.  XII,  No.  4. 
Bonn,  1899. 

Eulenberg  and  Bach :  "  Die  Artzliche  Schvdaufsicht  in  Gesundheits- 
lehre."  Das  Schulhaiis  und  das  Unterricotswesen  vom 
Hygienischen  Standpxmkte.  Zweite,  ungearbeitete  Auflage. 
Pages  1 194-12 14.     Berlin,  1899. 

Fell :  "  School  Diseases  and  Medical  Inspection."  Addresses,  Nat. 
Ed.  Asso.,  Washington,  D.  C,  1898,  pages  534-39. 

Fitz:  "The  Hygiene  of  Instruction  in  Primary  Schools."  Addresses, 
Nat.  Ed.  Asso.,  1898,  pages  544-50. 

Gaertner,  A. :  "Ansteckung  und  ansteckende  Krankheiten."  Rein's 
Encyklopadisches  Handbuch  der  Padagogik,  Vol.  I,  pages 
102-116.     Langensalza,  1895. 

Galton:    "Report  of  the  Anthropometric  Committee  of  the  British 
Association  for  1883." 
"Why  Do  we  Measure  Mankind?"     Lippincott's  Magazine,  Feb., 
1899,  pages  236-41. 

Gawronsky,  L. :  "Einige  vergleichende  Daten  iiber  die  zahnartzliche 
Hilfe  in  den  Mittelschulen  Moskaus."  International  Kongress 
fiir  Schulhygiene,  Vol.  Ill,  304-9. 

Gilbert:    "Researches  on  the  Mental  and  Physical  Development  of 
School  Children."     Studies  from  the  Yale  Laboratory,  1895. 
"Researches  upon  School  Children  and  College  Students."     Uni- 
versity of  Iowa,  Studies  in  Psychology,  Vol.  I,  pages  1-39. 


2o8  Medical  Inspection  of  Schools 

Gorst,  Sir  John  E. :  "The  Children  of  the  Nation:  How  their  Health 
should  be  Promoted  by  the  State."  "Medical  Inspection  of 
School  Children."  Pages  50-66.  New  York,  E.  P.  Button 
&Co. 

Greenwood:  "Heights  and  Weights  of  Children."  Report  of  the 
Board  of  Education  of  Kansas  City  Schools,  1 890-1.  Amer- 
ican Public  Health  Asso.  Reports,  Vol.  XVII,  pages  199-204. 

Gulick,  Luther  H. :  "Department  of  School  Hygiene."     Boston  Med. 

and  Surg.  Jour.,  July  25,  1907. 
"How  Can  the  School  make  Contribution  of  Permanent  Value?" 

Proceedings  of  the  Dept.  of  Superintendence,  Nat.  Ed.  Asso., 

Washington,  D.  C,  Feb.,  1908. 
"Departments  of  Hygiene  under  Boards  of  Education,"     School 

Hygiene,  Boston,  June,  1908. 

Gutenberg,  Berthold:  "Zum  Kapitel  der  Zahne  und  Zahnpflege  bei 
den  Schulkindem."  Zeitschrift  fiir  Schulgesimdheitspflege, 
1901,  pages  452-66. 

Harrington,  Thomas  F. :  "Medical  Inspection  in  Public  Schools." 
Proceedings  of  the  Dept.  of  Superintendence,  Nat.  Ed.  Asso., 
Washington,  D.  C,  Feb.,  1908. 

Hartwell :  Reports  of  the  Director  of  Physical  Training,  Boston,  1891, 
1894,  1896. 
"Application  of  the  Laws  of  Physical  Training  to  the  Prevention 
and  Cure  of  Stuttering."  Proceedings  of  the  Nat.  Ed.  Asso., 
1893,  pages  738-49. 
-  et  al.:  Anthropometry,  Papers  upon.  American  Statistics  Associa- 
tion, 1894. 

Hedler,  Albert :  "  Medical  Examination  of  the  Children  of  the  Franklin 
School."     Minneapolis  Jour.,  March  17,  1908. 

Heilman,  J.  D. :  "A  Clinic  Examination  Blank  for  Backward  Children 
in  the  PubHc  Schools."     Psych.  Clinic,  Dec.  15,  1907. 

Heitmuller,  G.  H. :  "Medical  Inspection  of  Schools."  Washington 
Med.  Ann.,  March,  1907. 

Henderson,  C.  R. :  "Dependent,  Defective,  and  Delinquent  Classes." 
Page  394.     Boston,  1901. 

Henie,  C. :  "  Untersuchimgen  iiber  die  Zahne  der  Volksschiiler  zu 
Hamar  in  Norwegen."  Zeitschrift  fiir  Schulgesimdheitspflege, 
Feb.,  1898,  pages  65-71. 


Bibliography  209 

Herdman,  Elliott  Kent:  "Medical  Inspection  of  Schools."  Public 
Health,  State  Dept.  of  Health,  Lansing,  Mich.,  Jan.-March, 
1908. 

Hertel :  "  Overpressure  in  the  High  Schools  of  Denmark."  London, 
1885. 

Hinchey :  "Medical  Inspection  of  School  Children."  Medical  Fort- 
nightly, pages  360  ff. 

Jackson,  Edward :  "  Considerations  regarding  Medical  Inspection  in 
PubHc  Schools."  Bulletin  of  the  Amer.  Aca.  of  Medicine, 
6:  923-32. 

Jackson :  "  Care  of  the  Eyes  during  School  Life."  Bulletin  of  the 
Amer.  Aca.  of  Med.,  Oct.,  1898,  Vol.  Ill,  No.  9,  page  517. 

James,  Dr.  J.  H. :  "  Suggestions  to  Teachers  Regarding  Visual  Defects 
of  School  Children,"     Mankato,  Minn. 

Jarrett,  Elizabeth:  "Health  of  our  High  School  Children."  New 
York  Med.  Record,  April  11,  1908. 

Jeffries,  B.  Joy  :  "Report  of  the  Examination  of  27,927  Children  for 
Color-Blindness."     Boston,  1880,  Rockwell  and  Churchill. 

Jessen,  Dr.  Ernst :  "  Kostenpunkt  einer  stadtischen  Schulzahn- 
klinik."  Internationales  Archiv  fiir  Schulhygiene,  Vol.  IV, 
No.  4. 
"Die  stadtische  Schulzahnklinik;  ihr  Verhaltnis  zu  Stadt,  Schule, 
und  ortsansassigen  Zahnartzten."  Odontolische  Blatter  XII, 
No.  7-8.     Berlin. 

Johnson,  G.  E.:  "Condition  of  the  Teeth  of  Children  in  Public 
Schools."     Pedagogical  Sem.,  March,  1901,  8:  45-58. 

Johnson,  H.  P. :  "  Medical  School  Inspection  in  the  City  of  New  York." 
Transactions,  Medical  Society  of  New  York,  1903,  pages 
183-9. 

Jordan,  Walter  R. :  "Medical  Inspection  of  School  Children."  Path- 
ologist, 8:   70-7. 

Kalle,  Fritz:  "Die  Losimg  der  Schulartzfrage  in  Wiesbaden." 
Deutsche  Vierteljahrsschrift  fiir  offentliche  Gesundheitspflege, 
1898,  Vol.  XXX,  pages  433-447- 

Keen,  Dora:  "Medical  Inspection  of  Schools."    Reprint  from  Phila- 
delphia  Med.   Jour.,    June    18,    1898;    also   Public   Health, 
August,  1898,  Vol.  III. 
14 


2IO  Medical  Inspection  of  Schools 

Key:  "School  Life  in  Relation  to  Growth  and  Health."  Pop.  Sci. 
Monthly,  1890-1,  Vol.  XXXVIII,  pages  107-112. 

Krohn:     "Habitual    Postures    of    School    Children."     Child    Study 
Monthly,  Oct.,  1895. 
"Nervous  Diseases  of  School  Children."     Child  Study  Monthly, 
April,  1896,  Vol.  I,  pages  354-68. 

Lederle,  Ernst  J. :  "Medical  Inspection  of  Schools."  Conference  of 
Eastern  Public  Education  Associations,  Bulletin  No.  2,  1904. 

Lee :  "  Interdependence  of  Healthy  Bodies  and  Healthy  Brains." 
Bulletin  of  the  Amer.  xA.ca.  of  Med.,  Oct.,  1898,  III,  page  534. 

Lee,  Joseph,  and  Margaret  Curtis  :  "  Medical  Inspection  in  the  Public 
Schools."     Leaflet  No.  7,  Mass.  Civic  League,  1906. 

Loring,  L.  G. :  "  Examinations  of  Eyes  of  Four  Hundred  and  Twenty 
School  Children."  Boston  Med.  and  Surg.  Jour,,  Dec.  13, 
1906;  abstract  in  Jour,  of  the  Amer.  Med.  Asso.,  Jan.  5,  1907, 
page  79. 

Lovett,  R.  W. :  "Medical  Inspection  of  Schools."  Boston  Med. 
and  Surg.  Jour  ,  Feb.  21,  1907. 

McCallie,  J.  M. :  "The  Vision  of  the  Pupils  of  an  Elementary  School, 
tested  by  the  Snellen  Alphabet  and  Illiterate  Cards."  Psych. 
Clinic,  Nov.  15,  1907,  I,  175-82. 

McDonald :    "  Children  with  Abnormalities,  Based  upon  the  Reports 
of  Teachers."     Reprint  from  Medical  Times  and  Register, 
Jime,  1899. 
"Growth  and  Sociological  Conditions."     Reprint  from  the  Boston 
Med.  and  Surg.  Journal,  Sept.  14,  1899. 

McMahon,  J.  P.:  "Necessity  for  Annual  Systematic  Examination  of 
School  Children's  Eyes,  Ears,  Noses  and  Throats  by  School 
Teachers."     Wisconsin  Med.  Jour.,  Dec,  1907. 

Mackenzie,  W.  Leslie  :  "The  Medical  Inspection  of  School  Children." 
Glasgow  and  Edinbvirgh,  1904. 
"The  Health  of  the  School  Child."     Methuen,  London,  1906. 

Macmillan,  D.  P. :  "The  Physical  and  Mental  Examination  of  Public 
School  Pupils  in  Chicago."  Charities  and  The  Commons, 
Dec.  22,  1906,  17:   529-35. 

Mahony,  John  J.:  "The  Problem  of  the  Poor  Pupil."  Education, 
Dec,  1907. 


Bibliography  2ii 

Mangenot :    L'inspection  hygienique  et  medicale  des   ecoles.     Page 
64.     Paris,  1887. 
L'examen  individual  et  la  bulletin  sanitaire  des  ecoliers.     Paris, 
1894. 

Martin,  Geo.  H. :  "School  Hygiene  in  Massachusetts."     Reprint  from 
71st  Report  of  the  Massachusetts  Board  of  Education. 

Menninger:    "Medical     Inspection     in     Schools."       Northwestern 

Monthly,  July,  1897,  pages  66-67. 

Mulford:   "The  Throat  of  the  Child."     Educational  Review,  March, 
1897,  XIII,  pages  261-72. 

Newmayer,  S.  W. :   "The  Trained  Nurse  in  the  Public  Schools  as  a 

Factor  in  the  Education  of  the  Children."     Amer.  Jour,  of 

Nursing,  Dec,  1906. 
"Physical  Defects  of  School  Children   Causing  Subnormal  and 

Mentally  Deficient  Pupils."     New  York  Med.  Jour.,  Nov.  2, 

1907. 
"A  Practical  System  of  Medical  Inspection  with  Trained  Nurses 

adapted  for   Public  Schools   of   Large   Cities."     New   York 

Med.  Jour.,  April  4,  1908. 
"Defective  Vision  and  the  Mentally   Subnormal   Child."     New 

York  Med.  Jour.,  May  9,  1908. 

Oppenheim:  "Development  of  the  Child."     New  York,  1898. 

Porter:  "The  Physical  Basis  of  Precocity  and  Dullness."  Transac- 
tions of  the  Aca.  of  Science  of  St.  Louis,  Nov.,  1893,  Vol.  VT, 
pages  161-81. 
"The  Relation  bet^-een  the  Growth  of  Children  and  Their  Devia- 
tion from  the  Physical  Type  of  Their  Sex  and  Age."  Trans- 
actions of  the  Aca.  of  Science  of  St.  Louis,  Nov.,  1893,  Vol. 
VI,  pages  233-50. 

Powell,  W.   B. :    "Medical   Inspection   of   Schools."     Addresses   of 
Nat.  Ed.  Asso.,  Washington,  D.  C,  1898,  pages  454-62. 

Prentice  :  "The  Eye  in  Its  Relation  to  Health."     Chicago,  1895, 

Punton  :  "  Relation  of  the  Science  of  Medicine  to  Pubhc  School  Educa- 
tion."    Kansas  City,  Mo. 

Randall :   "The  Hygienic  and  Scientific  Value  of  Examinations  of  the 
Eyes  and  Ears  of  School  Children."     Chicago,  1895. 
Report  of  Committee  on  Examination  and  Care  of  Eyes  during 
School  Life.     Chicago,  1895. 


212  Medical  Inspection  of  Schools 

Richards,  H.  M. :  "  Organized  Medical  Inspection  of  Schools." 
Public  Health,  Nov.,  1906,  19:  87-96. 

Risley :   "  Weak  Eyes  in  the  Public  Schools  of  Philadelphia."     Phila- 
delphia, 1881. 
"Defective   Vision    in    School    Children."     Educational   Review, 
New  York,  April,  1892,  III,  pages  348-54. 

Roberts,  Charles  :  "Manual  of  Anthropometry."     London,  1878. 
"The  Medical  Inspection  of,  and  Physical  Inspection  in.  Secondary 
Schools."     Royal  Commission  of  Secondary  Education,  1895, 
Vol.  V,  pages  352-75. 

Rogers,  Lina  L. :  "Nurses  in  the  Public  School."  Conference  of 
Eastern  Public  Education  Associations,  Bulletin  No.  2,  1904. 

Ryerson  :  "Defective  Vision  in  the  Public  Schools."  Transactions  of 
the  Canadian  Institute,  1889-90,  Toronto,  1891,  pages  26-7. 

Rose,  Karl :  "  Die  Zahnpflege  in  den  Schulen."  Zeitschrift  fur 
Schulgesundheitspflege,  8:  65-87. 

Routzahn,  E.  G. :  "A  City  School  Tooth-Clinic."  Chautauquan, 
Feb.,  1905,  40:  571-2. 

Schaefer,  Dr. :  "  Ueber  die  Gefahr  der  Verbreitung  ansteckender 
Krankheiten  durch  den  Schulbesuch  und  die  in  dieser  Hinsicht 
erforderlichen  Massnahmen."  Deutsche  Vierteljahrsschrift 
fiir  offentliche  Gesundheitspflege,  1898,  Vol.  XXX,  pages 
617-666. 

Scharfe,  Dr.  N.  W. :  "Municipal  Medical  Inspection  of  Schools." 
Philadelphia  Med.  Jour.,  April  29,  1899. 

Schenck,  H.  D. :  "The  Detection  of  Defects  of  the  Eye,  Ear,  Nose, 
and  Throat."  Report  of  the  7th  Anuual  Conference  of  Sani- 
tary Officers  of  the  State  of  New  York,  1907. 

Schiller,  Hermann  :  "Die  Schulartzfrage."  Sammlung  von  Abhand- 
lungen  aus  dem  Gebiete  der  Padagogischen  Psychologie  imd 
Physiologic,  Vol.  Ill,  No.  i,  page  56. 

Schmid,  Dr.  Fr. :  Die  Schulhygienischen  Vorschriften  in  der  Schweiz. 
Zurich,  1902. 

Schmid,  H.  D. :  "The  Detection  of  Communicable  Disease  in  School 
as  a  Part  of  Medical  School  Inspection." 
Report  of  the  7th  Annual  Conference  of  Sanitary  Ofl&cers  of  the 
State  of  New  York,  1907. 

Schubert,  Paul :  Das  Schulartzwesen  in  Deutschland.  Hamburg 
and  LeipsiCj  1905. 


Bibliography  213 

Schuschny,  H. :  "  Geschichte  und  Entwickelung  der  ungarischen 
Schulartzfrage."  Deutsche  Vierteljahrsschrift  fiir  offentliche 
Gesundheitspflege,  1897,  Vol.  XXIX,  page  530. 

Scripture:  "Tests  on  School  Children."  Educational  Review,  New 
York,  Jan.,  1893,  Vol.  V,  pages  52-61. 

Seashore,  C.  E. :  "  Suggestions  for  Tests  on  School  Children."  Educa- 
tional Review,  June,  1901,  22:   69-82. 

Shattinger,  Dr.  Charles  :  "  Municipal  Medical  Inspection  of  Schools." 
St.  Louis  Med.  Jour.,  April  28,  1S99, 

Shaw:  " School  Hygiene."    Page  252.    New  York,  1901. 

Shepherd,  Fred  S. :  "Medical  Inspection  of  Public  Schools."  (Supt., 
PubHc  Schools,  Asbury  Park,  N.  J.) 

Somers,  B.  S. :  "The  Medical  Inspection  of  Schools;  a  Problem  in 
Preventive  Medicine."     Medical  News,  Jan.  17,  1903. 

Southard:  "The  Modern  Eye;  with  an  Analysis  of  1300  Errors  of 
Refraction."     Page  32.     San  Francisco. 

Steiger:  "  Astigmatismus  und  Schule.  Schulhygienische  Studie." 
Correspondenzblatt  fiir  Schweizer  Artzte,  Bern,  1897,  No.  10, 
pages  289-98. 

Steinhardt,  Dr.  Ignaz :  Zum  augenbHcklichen  Stand  der  Schulartz- 
frage in  Deutschland.     Page  20.     Alunich,  1899. 

Stuver :  "  The  Relation  of  Food,  Air  and  Exercise  to  Healthy  Growth 
and  Development."  Reprint  from  Jour,  of  the  Amer.  Med. 
Asso.,  Feb.,  1898. 

Suck,  Hans :  Die  gesundheitliche  Uberwachung  der  Schule.  Ein 
Beitrag  zur  Losung  der  Schulartzfrage.  Page  36.  Hamburg 
and  Leipsic,  1899. 

Thompson,  T.  W. :  "The  Natural  History  of  Infectious  Diseases." 
Stevenson  &  Mvurphy's  Treatise  on  Hygiene,  II,  pages  243-381. 

Tomell,  M.  G. :  "  Medical  Supenasion  of  Secondary  Schools  in 
Sweden."  Med.  Press  and  Circular,  Sept.  25,  1907;  abstract 
in  Jour,  of  Amer.  Med.  Asso.,  Oct.  26,  1907,  page  1479. 

Twitmyer,  Geo.  W. :  "  Clinical  Studies  of  Retarded  Children."  Psych. 
Clinic,  June  15,  1907. 


214  Medical  Inspection  of  Schools 

Tyler,  John  N. :    "Abstract  of  8  Lectures  on  the  Physical  Basis  of 
Education."     Published  by  Twentieth  Century  Club,  Boston, 
1906. 
"The    Girl   in   the    Grammar   School."     Address   before   Amer. 
Phys.  Ed.  Asso.,  Dec.  26,  1906,  Springfield,  Mass. 

Veasey,  C.  A. :  "Importance  of  Active  Co-operation  between  Parents 
and  Teachers,  in  Order  to  Promote  and  Maintain  the  Health 
of  Children's  Eyes  during  School  Life."  Conference  of 
Eastern  Public  Education  Associations,  Bulletin  No.  2,  1904. 

Wald,  L.  D.:  "Medical  Inspection  of  Public  Schools."  Annals, 
Amer.  Aca.  of  Political  and  Social  Science,  1905,  Vol.  XXV, 
pages  290-298. 

Waldsworth,  R.  C.  W. :  "  Crusade  for  a  Thousand  Eyes."  Charities, 
10:  141-7. 

Warner:  "An  Inquiry  as  to  the  Physical  and  Mental  Condition  of 
School  Children."  Reprint  from  British  Med.  Jour.,  March 
12-19,  1892,  page  14. 

Report  on  the  Scientific  Study  of  the  Mental  and  Physical  Condi- 
tions of  Childhood.  (Report  is  based  upon  the  examinations 
of  100,000  children.)     London,  1895. 

"The  Study  of  Children  and  Their  School  Training."  Page  264. 
New  York,  1897, 

Weeks,  J.  E. :  "The  Care  of  the  Eyes  of  Children  While  at  School." 
Teachers  College  Record,  March,  1905,  6:  30-42. 

Wells,  David  W. :  "  Sight  and  Hearing  of  School  Children."  Joxir. 
of  Education,  51:  99-100;   117:   121-2,  Feb.  15,  22,  1900. 

West:  "Eye  Tests  on  Children."  Amer.  Jour,  of  Psych.,  August, 
1892,  Vol.  IV,  pages  595-6. 

"Worcester  School  Children:  the  Growth  of  Body,  Head  and 
Face."     Science  XXI,  Jan.  6,  1893,  pages  2-4. 

"The  Anthropometry  of  American  School  Children."  Proceed- 
ings, International  Congress,  Chicago,  1893,  P^g^  5°- 

"  Observations  of  the  Relation  of  Physical  Development  to  Intel- 
lectual Ability  Made  on  the  School  Children  of  Toronto, 
Canada."     Science,  New  Series,  1896,  IV,  pages  156-9. 

Williams,  Linsly  R. :  "A  Plea  for  the  Physical  Examination  of  all 
School  Children."     Jour,  of  Amer.  Med.  Asso.,  Nov.  16,  1907. 

Wingate  :  "National  Public  Health  Legislation."  North  American 
Review,  Nov.,  1898,  Vol.  167,  pages  527-533. 


Bibliography  215 

Wintsch,  C.  H. :  "Medical  School  Inspection."  North  American 
Journal  of  Homeopathy,  51:   210-7. 

Witmer,  Lightner:  "The  Hospital  School."  Ped.  Clinic,  Oct.  15, 
1907,  i:    138-46. 

Wolfe  :  "Defects  of  Sight."     Northwestern  Monthly,  July,  1897,  pages 

35-9- 
Wood  :  "  Kindergarten  and  Primary  Grade  Work  in  the  Public  Schools 

and  Its  Influence  on  the  Eyesight."     Bulletin  of  the  Amer. 

Aca.  of  Med.,  Oct.,  1898,  III,  pages  539-44. 

Worrill :  "  Deafness  among  School  Children."  Transactions  of  the 
Indiana  State  Medical  Society,  Indianapolis,  1883,  pages 
25-33- 

Wyche,  G. :  "  Inspection  of  School  Children,  with  Special  Reference  to 
Ear,  Nose,  and  Throat."     St.  Louis  Med.  Rev.,  May  4,  1907. 

Zirkle,  Homer  W. :  "Medical  Inspection  of  Schools."  Investiga- 
tions of  the  Dept.  of  Psychology  and  Education  of  the  Uni- 
versity of  Colorado,  June,  1902. 


ADDITIONAL  REFERENCES 

American  Academy  of  Medicine,  Vol.  Ill,  Oct.,  1898. 

"Brief  Statement  of  the  Results  obtained  by  the  Commissioner  of  the 
British  Dental  Association  appointed  to  Investigate  the  Teeth 
of  School  Children."  British  Dental  Journal,  London,  24: 
809-16. 

"Care  of  the  Eyes."     Sanitary  Home,  June,  1899,  page  79. 

"Causes  of  Contagious  and  Infectious  Diseases  in  Schools  (The)." 
Rocky  Mountain  Educator,  Dec.  23,  1899;  from  Indiana  School 
Journal. 

"Considerations  respecting  Medical  Inspection  in  the  Public  Schools." 
Bulletin  of  the  Amer.  Aca.  of  Medicine,  April,  1905,  6:  923-32; 
bibliography,  pages  929-32. 

"Cult  of  Infirmity  (The)."  Pubhc  Opinion,  Oct.  19,  1899,  page  493; 
from  National  Review,  London. 

"  Defective  Eyesight."     Pop.  Sci.  Monthly,  XXIV,  page  357. 

"  Defective  Vision  in  School  Children."     Educational  Review  V,  page  42. 

"  Dental  Clinic  for  School  Children  (New  York  City)."  School  Journal, 
Jan.  12,  1907,  74:   54. 


2i6  Medical  Inspection  of  Schools 

"Effects  of  Study  on  the  Eyesight."  Pop.  Sci.  Monthy,  Vol.  XXII, 
page  74. 

"Effects  of  Student  Life  upon  Eyesight."  Circular  No.  6,  Bureau  of 
Education,  page  29. 

"Examination  of  Railway  Employees."  Jour,  of  Amer.  Med.  Asso., 
Chicago,  Oct.  21,  1899. 

"Eye  Defects  in  Students  and  Children."  Ped.  Sem.,  Oct.,  1897; 
Science,  July  16,  1897. 

"Eye  Strain  and  'Optic  Crutches.'  "     Medical  Herald,  July,  1900. 

"Free  Eye  Glasses  for  School  Children."  School  Journal,  April  27, 
May  II,  June  29,  1907;  74:  419,  475,  487,  655.  Charities  and 
The  Commons,  April  27,  1907,  18:   130-1. 

"  Growth  of  Children."     Science,  Vol.  XIX,  pages  256,  281-2 ;  Vol.  XX, 

pages  351-2. 
"  How  to  Test  the  Vision."     Child  Study  Monthly,  I,  No.  6. 
"Hints  on  the  Use  and  Care  of  the  Eyes."     Scribner's  XIV,  700. 

"Hygiene  for  the  School  Boy  and  Girl."     The  Outlook,  Dec.  24,  1898, 

1016. 
"Influence  of  Schools  in  Accentuating  the  Spread  of  Certain  Infectious 

Diseases  (The)."     Lancet,  1898,  Jan.  21,  page  184;    Jan.  28, 

page  256;  Feb.  4,  page  330,  and  passim. 

"Inspection  of  Schools."     Educational  Times,   Dec.   i,    1894,   pages 

505-11- 
La  Medecine  Scolaire.     (Monthly  publication  of  the  Society  of  Medical 

Inspectors  of  Schools.)     Librarie,  Ch.  Delagrave,  Paris. 

"Medical  Examiner  for  our  Public  Schools  (A)."     Medical  Herald,  July, 

1900. 
"Medical  Inspection  of  Schools,"  in  "Making  a  Municipal  Budget," 

pages  92-107.     Bureau  of  Mxmicipal  Research,  New  York,  1907. 

Northwestern  Monthly,  July,  1897. 

"Nutrition.  Investigations  at  the  University  of  Tennessee."  Scien- 
tific American,  supplement  to,  March  11,  1899,  page  194;  also 
Bulletin  of  the  Department  of  Agriculture,  Nos.  29  and  53. 

"  Oiu-  Eyes  and  How  to  Take  Care  of  Them."  Atlantic  Monthly, 
XXVII,  62,  177,  332,  462,  636. 

Psychological  Clinic,  Vol.  I,  No.  i,  March  15,  1907.  (Most  scientific 
exponent  of  the  work  for  backward  and  mentally  retarded 
children.) 


Bibliography  217 

"Relation  of  Diseases  of  the  Eye  to  Diseases  in  General  (The)."  Medi- 
cal Times,  Jan.,  1898. 

"School  Life  and  Eyesight."     Pop.  Sci.  Monthly,  I,  page  766. 

"School  Work  and  Eyesight."     Science  XII,  page  207. 

"Shall  We  Put  Spectacles  on  School  Children?"  Pop.  Sci .  Monthly, 
XXV,  page  429. 

"Sight  Training."  Literary  Digest,  Oct.  9,  1898;  The  Hospital, 
London,  March  5,  1898. 

"Statistics  on  Blindness  and  Deafness."  New  York  Med.  Jour.,  July 
17,  1897,  page  85. 

"Suggestions  to  Teachers  and  School  Physicians  regarding  Medical 
Inspection."  Special  pamphlet,  Massachusetts  Board  of  Educa- 
tion, 1907. 

"Tests  on  School  Children."     Educational  Review,  V,  page  42. 

Zeitschrift  fiir  Schulgesundheitspflege.  Edited  by  Kotelmann  1888-98; 
since  that  time  by  Erismann,  Hamburg.  (This  contains  many 
articles  relative  to  the  progress  of  medical  inspection  the  world 
over.) 

SCHOOL  REPORTS 

Baltimore,  Md. :  Seventy-eighth  Annual  Report  of  the  Board  of  School 

Commissioners,  1906. 

Birmingham,   Ala. :  Annual    Report    of    the    Birmingham    Public 
Schools,  1907. 

Boston,  Mass. :  Annual  Report  of  the  PubUc  Schools,  1895. 

Twenty-seventh  Annual  Report  of  the  Superintendent  of  Public 
Schools  of  the  City  of  Boston,  1907. 

Brockton,  Mass. :   Annual  Report  of  the  Superintendent  of  Schook, 
1907. 

Cambridge,  Mass. :  Annual  Report  of  Public  Schools,  1898. 

Annual  Report  of  the  School  Committee,  prepared  by  the  Superin- 
tendent of  Schools,  Cambridge,  Mass.,  1907. 

Camden,  N.  J. :  Annual  Report  of  the  Board  of  Education,  1906. 

Chicago,  111. :  Forty-sixth  Annual  Report  of  the  Board  of  Education, 
1900. 

Cincinnati,  0. :  Seventy-eighth  Annual  Report  of  the  Public  Schools  of 
Cincinnati,  O.,  1907. 


2i8  Medical  Inspection  of  Schools 

Cleveland,  0. :  Annual  Report  of  the  Board  of  Education,  Cleveland, 
O.,  1901. 
Annual  Report  of  the  Superintendent  of  Schools,  Cleveland,  O., 
1907. 

Dallas,  Texas  :  Eleventh  Biennial  Report  of  the  Dallas  Public  Schools, 
1906. 

Dayton,  0. :  Annual  Report  of  the  Board  of  Education  of  the  City 
School  District  of  Dayton,  O.,  1907. 

Fall  River,  Mass. :  Annual  Report  of  the  City  of  Fall  River,  1907. 

Fitchburg,  Mass. :  Thirty-fifth  Annual  Report  of  the  School  Committee 
of  the  City  of  Fitchburg,  1907. 

Harrisburg,  Pa. :  Annual  Report  of  the  Public  Schools  of  Harrisbvurg, 
Pa.,  1907. 

Hoboken,  N.  J. :  Annual  Report  of  the  School  Department  of  Ho- 
boken,  N.  J.,  1907. 

Lawrence,  Mass. :   Sixtieth  Annual  Report  of  the  School  Committee 
of  the  City  of  Lawrence,  Mass.,  1906. 
Sixty-first  Annual  Report  of  the  School  Committee  of  the  City  of 
Lawrence,  Mass.,  1907. 

Los  Angeles,  Cal. :  Annual  Report  of  the  Board  of  Education  of  the 
City  of  Los  Angeles,  Cal.,  1906-7. 

Lowell,  Mass. :  Eighty-second  Report  of  the  School  Committee  of  the 
City  of  Lowell,  and  Forty-fourth  Annual  Report  of  the  Super- 
intendent of  Public  Schools,  1907. 

Milwaukee,  Wis. :  Annual  Report  of  the  Board  of  School  Directors, 

Milwaukee,  1900. 
Forty-eighth  Annual  Report  of  the  Board  of  School  Directors  of  the 
City  of  Milwaukee,  1907. 

Newark,  N.  J. :  Fifty-first  Annual  Report  of  the  Board  of  Education 
of  the  City  of  Newark,  N.  J.,  1907. 

Newburyport,  Mass. :  Annual  Report  of  the  School  Committee  by 
the  Superintendent  of  Schools  of  the  City  of  Newbviryport,  1907. 

New  Haven,  Conn. :  Annual  Report  of  the  Board  of  Education  of  New 
Haven  City  School  District,  New  Haven,  1907. 

Newton,  Mass. :  Annual  Report  of  the  School  Committee  of  the  City 
of  Newton,  Mass.,  1906. 


Bibliography  219 

New  York,  N.  Y. :  Ninth  Annual  Report  of  the  City  Superintendent  of 
Schools,  City  of  New  York,  1907. 

Northampton,  Mass. :    Twenty-third  Annual  Report  of  the  School 
Committee  of  the  City  of  Northampton,  Mass.,  1906. 
Twenty-fourth  Annual  Report  of  the  School  Committee  of  the  City 
of  Northampton,  Mass.,  1907. 

Pawtucket,  R.  I. :  School  Report,  1901. 

Reading,  Pa. :  Minutes  of  the  Reading  School  Board,  March  15,  1904. 

San  Antonio,  Texas  :  Annual  Report  of  the  San  Antonio  School  Board, 
1907. 

Somerville,  Mass. :  Thirty-sixth  Annual  Report  of  the  School  Com- 
mittee of  the  City  of  Somerville,  Mass.,  1907. 

Syracuse,  N.  Y. :  Fifty-eighth  and  Fifty-ninth  Annual  Reports  of  the 
Department  of  Public  Instruction  of  the  City  of  S}Tacuse, 
1906-7. 

Waltham,  Mass. :  Annual  Report  of  the  School  Committee  and  Super- 
intendent of  Schools  of  Waltham,  Mass.,  1908. 

Wilmington,  Del. :  Thirty-fourth  Annual  School  Report  of  the  City  of 
Wilmington,  Del.,  1905. 

Yonkers,  N.  Y. :  Twenty-seventh  Annual  Report  of  the  Board  of  Edu- 
cation in  the  City  of  Yonkers,  N.  Y.,  1907. 


REPORTS  FROM  BOARDS  OF  HEALTH 

Briinn,  Austria:    Dritter  Bericht  liber  die  Tatigkeit  der  stadt.     Be- 
zirksartzte  in  Briinn  als  Schulartzte,  1903. 
Vierter  Bericht  iiber  die  Tatigkeit  der  stadt.     Bezirksartzte  in 
Briinn  als  Schvilartzte,  1906-7. 

Cambridge,  Mass. :  Annual  Report  of  the  Board  of  Health,  Cam- 
bridge, 1896. 

Everett,  Mass. :  Fifteenth  Annual  Report  of  the  Board  of  Health,  1907. 

Montclair,  N.  J. :  Thirteenth  Report  of  the  Board  of  Health,  1907. 

New  York,  N.  Y. :  Working  Plan  of  the  System  of  Medical  Inspection 
and  Examination  of  School  Children  in  the  City  of  New  York, 
Department  of  Health,  New  Y^ork,  1906. 

Springfield,  Mass. :  Annual  Report  of  the  Board  of  Health,  1907. 


220  Medical  Inspection  of  Schools 

OTHER  REPORTS 

Commissioner  of  Education  :  Report  of  the  Commissioner  of  Educa- 
tion, 1897-8,  Vol.  II,  "Medical  Inspection  of  Schools,"  pages 
1489-1512. 

Report  of  the  Commissioner  of  Education,  1902,  "Medical  Inspec- 
tion of  Schools  Abroad,"  pages  509-526. 

Report  of  the  Commissioner  of  Education,  1902,  "Report  of  Com- 
mittee on  Statistics  of  Defective  Sight  and  Hearing  of  Public 
School  Children,"  pages  2143-2155. 

Report  of  the  Commissioner  of  Education,  1906,  "Medical  Inspec- 
tion of  School  Children,"  Vol.  I,  page  327. 

Detroit,  Mich. :  Bulletin  No.  i.  Child  Study  Committee,  Detroit 
Public  Schools,  Dec,  1907. 

Dimdee,  Scotland  :  Report  on  Housing  and  Industrial  Conditions  and 
Medical  Inspection  of  School  Children.     Dundee  Social  Union, 

Dundee,  1905. 

Dunfermline,  Scotland :  First  Annual  Report  of  Medical  Inspection 
of  School  Children,  Dunfermline,  1906. 
Second  Annual  Report  of  Medical  Inspection  of  School  Children, 
Dunfermline,  1907. 

Edinburgh,  Scotland :  Report  on  the  Physical  Condition  of  1400 
School  Children  in  the  City  of  Edinburgh,  together  with  some 
account  of  their  Homes  and  Surroundings.     London,  1906. 

Harrisburg,  Pa. :  Report  of  the  Special  Committee  to  Investigate  and 
Report  on  Medical  Inspection  in  the  Schools.  Harrisbiu-g 
School  District,  Harrisburg,  Pa.,  April  27,  1908. 

London,  England  :  Report  of  the  Education  Committee  of  the  London 
County  Council,  Submitting  the  Report  of  the  Medical  Officer 
(Education)  for  the  Year  ended  31st  March,  1905. 

Report  of  the  Education  Committee  of  the  London  County  Coimcil, 
Submitting  the  Report  of  the  Medical  Officer  (Education)  for 
the  Year  ended  31st  March,  1906. 

Report  of  the  Education  Committee  of  the  London  Coimty  Council, 
Submitting  the  Report  of  the  Medical  Officer  (Education)  for 
the  Year  ended  31st  March,  1907. 

Board  of  Education.  Memorandum  on  Medical  Inspection  of 
Children  in  PubUc  Elementary  Schools,  under  Section  13  of 
the  Education  (administrative  provisions)  Act,  1907.  London, 
1907,  Eyre  &  Spottiswoode.  (Great  Britain  Board  of  Educa- 
tion, circular  576.) 

Report  of  International  Committee  on  Medical  Inspection  and 


Bibliography  221 

Feeding   of   Children   attending   Public   Elementary   School. 
2  v.,  London,  Wyman  &  Sons,  1905. 

Lucerne,  Switzerland  :  Bericht  und  Antrag  des  Stadtrates  von  Luzem 
betreffend  Errichtung  einer  Schulpoliklinik.  Lucerne,  Dec.  8, 
1906. 

Massachusetts  (Board  of  Education)  :   Sixty-fourth  Annual  Report 
of  the  Board  of  Education,  1899-1900,  pages  375-380. 
Seventieth  Annual  Report  of  the  Board  of  Education,  1905-1906, 
pages  110-118.     "Medical  Inspection  in  the  PubUc  Schools." 

New  York  City:  New  York  Committee  on  the  Physical  Welfare  of 
School  Children.  "Physical  Welfare  of  School  Children." 
Quarterly  of  the  American  Statistical  Association,  June,  1907. 


Appendix  I 


"  SUGGESTIONS  TO  TEACHERS  AND  SCHOOL  PHYSICIANS 
REGARDING  MEDICAL  INSPECTION  " 

Issued  by  the  Massachusetts  Board  of  Education 

Commonwealth  of  Massachusetts 
State  House,  Boston,  Jan.  23,  1907. 

In  order  to  render  the  medical  inspection  required  by  chapter  502, 
Acts  of  1906,  effective  and  uniform  throughout  the  State,  His  Excel- 
lency Governor  Guild  appointed  a  committee  to  prepare  a  circular  of 
advice  to  the  school  physicians  of  the  State. 

This  committee  consisted  of  Dr.  Henry  P.  Walcott,  Dr.  Charles 
Harrington  and  Dr.  Juhan  A.  Mead,  representing  the  State  Board  of 
Health;  Mrs.  Ella  Lyman  Cabot,  Mr.  George  I.  Aldrich  and  Mr. 
George  H.  Martin,  representing  the  Board  of  Education;  and  Dr. 
Robert  W.  Lovett,  Dr.  Harold  Williams  and  Dr.  W.  H.  Devine,  repre- 
senting the  medical  profession. 

A  sub-committee  of  this  body  arranged  for  conferences  with  the 
heads  of  departments  and  others  connected  with  the  medical  schools  and 
hospitals  in  and  about  Boston,  and  with  physicians  who  have  had 
experience  in  school  inspection.  These  gentlemen  have  given  freely 
of  their  time  and  thought,  and  have  furnished  to  the  committee  the 
suggestions  contained  in  this  circular. 

These  suggestions  cover  the  ground  included  in  the  clause  in  section 
5  of  the  law:  "The  school  committee  of  every  city  and  town  shall 
cause  every  child  in  the  public  schools  to  be  separately  and  carefully 
tested  and  examined  at  least  once  in  every  school  year,  to  ascertain 
whether  he  is  suffering  from  defective  sight  or  hearing,  or  from  any 
other  disability  or  defect  tending  to  prevent  his  receiving  the  full  benefit 
of  his  school  work,  or  requiring  a  modification  of  the  school  work  in 


Suggestions  to  Teachers  and  School  Physicians      223 

order  to  prevent  injury  to  the  child  or  to  secure  the  best  educational 
results." 

The  Board  of  Education  issues  this  circular  in  the  assurance  that 
it  represents  the  highest  professional  authority  in  the  specialties  covered 
by  the  law,  and  commends  it  to  the  careful  attention  of  all  teachers, 
school  physicians  and  other  school  ofl&cers. 

The  following  are  the  subjects  treated,  with  the  names  of  the  physi- 
cians who  have  contributed  suggestions: — • 

1.  Infectious  Diseases. — Dr.  John  H.  McCoUom. 

2.  The  Eye. — Dr.  Myles  Standish,  Dr.  Henry  B.  Chandler,  Dr. 
Charles  H.  Williams,  Dr.  David  W.  Wells. 

3.  The  Ear. — Dr.  Clarence  J.  Blake,  Dr.  D.  Harold  Walker. 

4.  The  Throat  and  Nose. — Dr.  Samuel  W.  Langmaid,  Dr.  Algernon 
Coolidge,  Jr.,  Dr.  Frederic  C.  Cobb,  Dr.  George  B.  Rice. 

5.  The  Skin. — Dr.  John  T.  Bowen,  Dr.  James  S.  Howe,  Dr.  George 
F.  Harding,  Dr.  Charles  J.  White,  Dr.  C.  Morton  Smith,  Dr.  John  L. 
Coffin. 

6.  Diseases  of  Bones  and  Joints. — Dr.  Edward  H.  Bradford,  Dr. 
Augustus  Thorndike,  Dr.  Chales  F.  Painter,  Dr.  George  H.  Earl,  Dr. 
Robert  Soutter. 

7.  Children's  Diseases. — Dr.  Thomas  M.  Rotch,  Dr.  John  L. 
Morse,  Dr.  John  H.  Moore,  Dr.  Robert  W.  Hastings,  Dr.  Edmund  C. 
Stowell. 

8.  The  Teeth. — Dr.  Edward  W.  Branigan,  Dr.  George  A.  Bates, 
Dr.  Eugene  H.  Smith,  Dr.  Samuel  A.  Hopkins. 

9.  Nervous  Diseases. — Dr.  James  J.  Putnam,  Dr.  George  L.  Walton, 
Dr.  Morton  Prince,  Dr.  William  N.  BuUard,  Dr.  Edward  W.  Taylor, 
Dr.  John  J.  Thomas,  Dr.  Walter  E.  Fernald. 

10.  School  Hygiene. — Dr.  Henry  J.  Barnes. 

11.  School  Furyiiture. — Dr.  Frederick  J.  Cotton,  Dr.  R.  Clipston 
Sturgis. 

12.  School  Inspectors. — Dr.  George  S.  C.  Badger,  Dr.  H.  Lincoln 
Chase,  Dr.  Harry  M.  Cutts. 

George  H.  Martin, 

Secretary 


224  Medical  Inspection  of  Schools 

DISEASES 
Infectious  Diseases 

Diphtheria. — It  is  a  well-recognized  fact  that  nasal  diphtheria  of  a 
mild  type  without  constitutional  disturbance  is  one  of  the  most  impor- 
tant factors  in  causing  the  spread  of  the  disease,  and  also  that  children 
very  frequently  have  profuse  discharges  from  the  nose.  It  therefore 
follows  that,  in  order  properly  to  inspect  the  public  schools,  it  is  impor- 
tant that  cultures  should  be  taken  from  the  nose  in  every  case  where 
there  is  a  persistent  discharge,  particularly  if  there  is  any  excoriation 
about  the  nostrils. 

The  throat  should  be  examined  at  varying  intervals,  depending 
upon  the  physical  condition  of  the  children.  Any  hoarseness  or  any 
thickness  of  the  voice  should  caiise  an  examination  of  the  throat.  If 
the  tonsils  are  enlarged,  if  the  mucous  membrane  is  congested,  if  there 
is  swelling  of  the  palate,  a  culture  should  be  taken.  These  symptoms 
precede  diphtheria. 

A  child  with  positive  cultures  should  be  excluded  from  school  until 
two  consecutive  negative  cultures  at  an  interval  of  forty-eight  hours 
have  been  obtained. 

Scarlet  Fever. — If  there  is  a  sudden  attack  of  vomiting,  if  there  is 
any  redness  of  the  throat,  if  the  child  complains  of  headache,  if  there 
is  an  unexplained  rise  in  temperature,  the  child  should  be  isolated  at 
once.  Any  desquamation  (peeling  of  the  skin)  should  be  looked  upon 
with  suspicion.  If  there  are  any  breaks  at  the  finger  tips,  if  on  pressing 
the  pulp  of  the  finger  there  is  a  white  line  at  the  juncttire  of  the  nail 
with  the  pulp  of  the  finger,  particularly  if  this  occurs  in  the  majority 
of  the  finger  tips,  the  child  should  be  excluded  from  the  school. 

A  child  who  has  had  scarlet  fever  should  not  return  to  school  until 
the  process  of  desquamation  has  been  entirely  completed,  and  all  dis- 
charge from  the  nose  and  ears  has  ceased. 

Measles. — Rvmning  from  the  nose  and  slight  intolerance  of  light 
may  call  for  an  examination  of  the  mucous  membrane  of  the  mouth  for 
Koplik's  sign.  Koplik's  sign,  so  called,  is  the  presence  on  the  lining 
membrane  of  the  mouth,  near  the  molar  teeth,  of  minute  pearly  white 
blisters,  without  any  inflammation  arotmd  them.  There  may  be  only 
two  or  three  of  these  blisters,  and  they  may  easily  escape  detection  if  the 


Suggestions  to  Teachers  and  School  Physicians      225 

patient  is  not  carefully  examined  in  a  good  light.  These  blisters  are 
certain  forerunners  of  an  attack  of  measles. 

No  child  should  return  to  school  after  an  attack  of  measles  until 
the  desquamation  is  entirely  completed,  and  the  child  has  recovered 
from  the  intercurrent  bronchitis. 

Mumps. — Any  swelling  or  tenderness  in  the  region  of  the  parotid 
glands  (situated  behind  the  angle  of  the  jaw)  should  be  looked  upon 
with  suspicion.  It  is  important  to  notice  any  enlargement  or  swelling 
about  Steno's  duct  (inside  the  mouth,  opposite  the  second  upper  molar 
tooth),  as  this  is  a  very  frequent  symptom  of  mumps. 

A  child  should  be  excluded  from  school  until  one  week  has  elapsed 
after  the  disappearance  of  all  swelling  and  tenderness  in  the  region  of 
the  parotid  glands. 

Whooping-cough. — A  persistent  paroxysmal  cough,  frequently  ac- 
companied with  vomiting,  no  matter  whether  there  is  any  distinct 
whoop  or  not,  is  indicative  of  whooping-cough.  In  cases  of  whooping- 
cough  of  long  standing,  even  if  there  has  been  no  distinct  whoop,  an 
ulcer  on  the  band  connecting  the  lower  surface  of  the  tongue  with  the 
floor  of  the  mouth  is  found  in  a  certain  number  of  cases.  If  there  is 
no  distinct  ulceration,  there  may  be  a  marked  congestion  of  the  band. 

As  long  as  there  is  any  cough,  the  child  who  has  had  whooping-cough 
should  be  looked  upon  with  suspicion. 

Varicella  {Chicken  Pox). — A  few  black  crusts  scattered  over  the 
body  are  evidences  of  an  attack  of  chicken  pox.  The  crusting  seen  in 
impetigo  must  be  differentiated  from  that  of  chicken  pox.* 

No  child  should  return  to  school  until  all  crusts  have  disappeared 
from  the  body,  particularly  from  the  scalp,  for  in  this  region  the  crusts 
remain  longer  than  elsewhere. 

The  Eyes 

[Supplement  to  circular  already  issued] 

There  are  certain  children  who  show  normal  vision  by  the  ordinary 

tests,  yet  whose  parents  should  be  notified  to  have  the  eyes  examined. 

These  are:    (i)  children  who  habitually  hold  the  head  too  near  the 

book  (less  than  twelve  to  fourteen  inches);   (2)  children  who  frequently 

*  See  Diseases  of  the  Skin. 
IS 


226  Medical  Inspection  of  Schools 

complain  of  headaches,  especially  in  the  latter  portion  of  school  hours; 
(3)  children  in  whom  one  eye  deviates  even  temporarily  from  the  normal 
position. 

It  should  be  remembered  that  the  following  symptoms  are  at  times 
indicative  of  trouble  with  the  eyes:  (i)  habitual  scowling,  and  wrinkling 
of  the  forehead  when  reading  or  writing;  (2)  twitching  of  the  face; 
(3)  inattention  and  slowness  in  book  studies  in  a  child  otherwise  bright. 


The  Ears 
See  circular  of  directions  for  testing  hearing,  already  in  hands  of 
teachers. 

The  Throat  and  Nose 

In  all  cases  of  acute  illness  the  throat  should  be  examined  for  the 
presence  of  the  eruption  of  scarlet  fever  and  measles  and  for  the  exuda- 
tion or  membrane  of  tonsillitis  and  diphtheria,  and  a  culture  taken  in 
any  suspected  case  of  the  latter. 

The  presence  of  discharge  from  the  nose  should  be  noted,  and 
if  it  is  thick  and  creamy,  a  culture  should  always  be  taken.  In  all  cases 
of  severe  hoarseness,  with  diflacult  breathing,  diphtheria  should  be 
suspected.  If  the  discharge  from  the  nose  is  only  from  one  nostril,  a 
foreign  body  in  the  nose  should  be  looked  for. 

In  cases  of  chronic  nasal  obstruction,  as  evinced  by  mouth-breathing, 
snoring,  continual  post-nasal  catarrh  or  recurring  ear  trouble,  the 
presence  of  an  adenoid  growth  (third  tonsil)  should  be  suspected,  and 
the  child  referred  for  special  examination  and  treatment.  As  a  rule, 
digital  examination  for  adenoids  should  be  made  only  by  the  operating 
surgeon.  Obviously  large  tonsils,  recurring  tonsillitis  and  enlargement 
of  the  glands  of  the  neck,  suggest  the  advisability  of  referring  the  child 
to  the  family  physician  as  to  the  propriety  of  removing  the  tonsils. 

Recurring  nose-bleed  should  be  referred  for  special  treatment. 

In  cases  of  eczema  about  the  nostrils,  a  cause  may  be  sought  in 
pediculi  capitis  (head  lice). 

In  referring  cases  for  treatment,  school  physicians,  in  addition  to  the 
diagnosis,  should  state  the  symptoms  upon  which  the  diagnosis  is 
based,  for  the  benefit  of  the  family  physician  or  specialist. 


Suggestions  to  Teachers  and  School  Physicians    227 

Diseases  of  the  Skin 

Scabies  (the  Itch). — A  contagious  skin  disease,  due  to  an  animal 
parasite  which  burrows  in  the  skin,  causing  intense  itching  and  scratch- 
ing. The  disease  usually  begins  upon  the  hands  and  arms,  spreading 
over  the  whole  body,  but  does  not  affect  the  face  and  scalp.  Between 
the  fingers,  on  the  front  of  the  wrist,  at  the  bend  of  the  elbows  and  near 
the  arm-pits  are  favorite  locations  for  the  disease;  but  in  persons  of 
cleanly  habits  the  disease  may  not  show  at  all  upon  the  hands,  and  its 
real  nature  is  determined  only  after  a  most  thorough  and  careful  examina- 
tion. There  is  a  great  variation  in  the  extent  and  severity  of  this  disease, 
lack  of  personal  care  and  cleanliness  always  favoring  its  development. 
Scratching  soon  brings  about  an  infection  of  the  skin  with  some  of  the 
pus-producing  germs,  and  the  disease  is  then  accompanied  by  impetigo, 
or  a  pus  infection  of  the  skin. 

At  the  present  time  itch  is  very  common  and  widespread,  and, 
because  of  the  great  variation  in  its  severity,  mild  cases  have  been  mis- 
taken for  hives,  eczema,  etc.,  the  real  condition  not  being  recognized, 
and  the  disease  spread  in  consequence.  All  children  who  are  scratching 
or  have  an  irritation  upon  the  skin  should  be  examined  for  scabies. 

It  is  very  important  that  all  infected  members  of  a  family  be  treated 
till  cured,  else  the  disease  is  passed  back  and  forth  from  one  to  another. 
It  is  also  important  that  all  underclothing,  bedding,  towels,  etc.,  things 
that  come  in  contact  with  the  body,  be  boiled  when  washed. 

All  cases  of  scabies  should  be  excluded  from  school  until  cured. 

Pediculi  Capitis  {Head  Lice). — An  extremely  common  accident 
among  children,  either  from  wearing  each  others'  hats  and  caps,  or 
hanging  them  on  each  others'  pegs,  or  from  combs  and  brushes.  No 
person  should  be  blamed  for  having  lice, — only  for  keeping  them. 

The  irritation  caused  by  vermin  in  the  scalp  leads  to  scratching, 
which  in  turn  causes  an  inflammation  of  the  skin  of  the  neck  and  scalp. 
The  skin  then  easily  becomes  infected  with  some  of  the  pus-producing 
germs,  and  large  or  small  scabs  and  crusts  are  formed  from  the  dried 
matter  and  blood.  Along  with  this  condition  the  glands  back  of  the 
ears  and  in  the  neck  become  swollen,  and  may  be  very  painful  and 
tender. 

The  condition  of  pediculosis  is  most  easily  detected  by  looking  for 


228  Medical  Inspection  of  Schools 

the  eggs  (nits),  which  are  always  stuck  onto  the  hair,  and  are  not  readily 
brushed  off.  The  condition  is  best  treated  by  killing  the  living  parasites 
with  crude  petroleum,  and  then  getting  rid  of  the  nits.  With  boys, 
this  is  easy, — a  close  hair  cut  is  all  that  is  needed;  with  girls,  by  using 
a  fine-toothed  comb  wet  in  alcohol  or  vinegar,  which  dissolves  the  attach- 
ment of  the  eggs  to  the  hair.  All  combs  and  brushes  must  be  carefully 
cleansed. 

Children  with  pediculosis  should  be  excluded  from  school  until  their 
heads  are  clean.  By  chapter  383,  Acts  of  1906,  parents  who  neglect 
or  refuse  to  care  for  their  children  in  this  respect  may  be  prosecuted 
under  the  compulsory  attendance  law. 

Ringworm. — A  vegetable  parasitic  disease  of  the  skin  and  scalp. 
When  it  occurs  upon  the  skin,  it  yields  readily  to  treatment;  but  upon 
the  scalp  it  is  extremely  chronic.  Ringworm  of  the  skin  usually  appears 
on  the  face,  hands  or  arms, — rarely  upon  the  body, — in  varying  sized 
more  or  less  perfect  circles.  One  or  more,  usually  not  widely  separated, 
may  be  present  at  the  same  time.  All  ringed  eruptions  upon  the  skin 
should  be  examined  for  ringv^^orm. 

When  the  disease  attacks  the  scalp,  the  hairs  fall  or  break  off  near 
the  scalp,  leaving  dime  to  dollar  sized  areas  nearly  bald.  The  scalp  in 
these  areas  is  usually  dry  and  somewhat  scaly,  but  may  be  swollen  and 
crusted.  The  disease  spreads  at  the  circumference  of  the  area,  and 
new  areas  arise  from  scratching,  etc. 

Another  disease,  somewhat  like  ringworm  of  the  scalp,  is  known  as 
favus, — a  disease  much  more  common  in  Europe  than  America.  In 
this  disease  quite  abundant  crusts  of  a  yellowish  color  are  present  where 
the  process  is  active.  The  roots  of  the  hair  are  killed,  so  that  the  loss 
of  hair  from  this  disease  is  permanent,  a  scar  remaining  when  the  condi- 
tion is  cured. 

Care  must  be  taken  to  see  that  all  combs  and  brushes  are  thoroughly 
cleansed,  and  to  prevent  children  wearing  each  others'  hats,  caps,  etc. 

Children  with  ring^^orm  should  not  be  allowed  to  attend  school. 

Impetigo. — A  disease  characterized  by  few  or  many  large  or  small 
flat  or  elevated  pustules  or  festers  upon  the  skin.  The  condition  is  often 
secondary  to  irritation  or  itching  diseases  of  the  skin  (hives,  lice,  itch), 
and  scratching  starts  up  a  pus  infection. 

The  disease  most  often  appears  upon  the  face,  neck,  and  hands; 


Suggestions  to  Teachers  and  School  Physicians     229 

less  often  upon  the  body  and  scalp.  The  size  of  the  spots  varies  very 
much,  and  they  often  run  together  to  form  on  the  face  large  superficial 
sores,  covered  with  thick,  dirty,  yellowish  or  brownish  crusts. 

The  disease  is  contagious,  and  often  spread  by  towels  and  things 
handled. 

Children  having  impetigo  should  not  be  allowed  to  attend  school 
until  all  sores  are  healed  and  the  skin  is  smooth. 

Diseases  of  the  Bones  and  Joints 
All  noticeable  lameness,  whether  sudden  or  continued,  may  indicate 
serious  joint  trouble,  or  may  be  due  to  improper  shoes.     These  cases, 
as  well  as  curvatures  of  the  spine,  as  indicated  by  habitual  faulty  postures 
at  the  desk  or  in  walking,  should  be  referred  for  medical  inspection. 

Spinal  curvature  should  be  suspected  when  one  shoulder  is  habitually 
raised  or  dropped,  or  when  the  child  leans  to  the  side,  or  shows  persis- 
tent round  shoulders. 

Complaints  of  persistent  "growing  pains"  or  "rheumatism"  may 
be  the  earliest  signs  of  serious  disease  of  the  joints 

Some  Gener.\l  Symptoms  of  Disease  in  Children  "\\TaicH  Teacher 

SHOULD  NOTICE,  AND  ON  ACCOUNT  OF  WHICH  THE  CHILDREN 
SHOULD  BE  REFERRED  TO  THE  SCHOOL  PHYSICIAN. 

Emaciation. — This  is  a  manifestation  of  many  chronic  diseases, 
and  may  point  especially  to  tuberculosis. 

Pallor. — Pallor  usually  indicates  anaemia.  Pallor  in  young  girls 
usually  means  chlorosis, — a  form  of  anaemia  peculiar  to  girls  at  about 
the  age  of  puberty.  It  is  usually  associated  with  shortness  of  breath; 
the  general  condition  otherwise  usually  appears  good.  Pallor  may 
also  be  a  manifestation  of  disease  of  the  kidneys;  this  is  almost  invariably 
the  case  if  it  is  associated  with  puffiness  of  the  face. 

Puffiness  of  the  Face. — This,  especially  if  it  is  about  the  eyes,  points 
to  disease  of  the  kidneys;  it  may,  however,  merely  indicate  nasal  ob- 
struction. 

Shortness  of  Breath. — Shortness  of  breath  usually  indicates  disease 
of  the  heart  or  lungs.  If  it  is  associated  with  blueness,  the  trouble  is 
usually  in  the  heart.  If  it  is  associated  with  cough,  the  trouble  is  more 
likely  to  be  in  the  lungs. 


230  Medical  Inspection  of  Schools 

Swellings  in  the  Neck. — These  may  be  due  to  mumps  or  enlarge- 
ment of  the  glands.  The  swelling  of  mumps  comes  on  acutely,  and  is 
located  just  behind,  just  in  front  and  below  the  ear.  Swollen  glands 
are  situated  lower  in  the  neck,  or  about  the  angle  of  the  jaw.  They  may 
come  on  either  acutely  or  slowly.  If  acutely,  they  mean  some  acute 
condition  in  the  throat.  If  slowly,  they  are  most  often  tubercular. 
They  may  also  be  the  result  of  irritation  of  the  scalp,  or  lice  in  the  hair. 

General  Lassitude,  and  Other  Evidences  oj  Sickness. — These  hardly 
need  description,  but  may,  of  course,  mean  the  presence  or  onset  of 
any  of  the  acute  diseases. 

Flushing  of  the  Face. — This  very  often  means  fever,  and  on  this 
account  should  be  reported. 

Eruptions  of  any  Sort. — All  eruptions  should  be  called  to  the  atten- 
tion of  the  physician.  It  is  especially  important  to  notice  eruptions, 
because  they  may  be  the  manifestations  of  some  of  the  contagious 
diseases.  The  eruption  of  scarlet  fever  is  of  a  bright  scarlet  color,  and 
usually  appears  first  on  the  neck  and  chest,  spreading  thence  to  the 
face.  There  is  often  a  pale  ring  about  the  mouth  in  scarlet  fever, 
which  is  very  characteristic.  There  is  usually  a  sore  throat  in  connec- 
tion with  the  eruption.  The  eruption  of  measles  is  a  rose  or  purplish 
red,  and  is  in  blotches  about  the  size  of  a  pea.  It  appears  first  on  the 
face,  and  is  usually  associated  with  running  of  the  nose  and  eyes.  The 
eruption  of  chicken  pox  appears  first  as  small  red  pimples,  which  quickly 
become  small  blisters. 

A  Cold  in  the  Head,  with  Running  Eyes. — This  should  be  noticed, 
because  it  may  indicate  the  onset  of  measles. 

Irritating  Discharge  from  the  Nose. — A  thin,  watery  nasal  discharge, 
which  irritates  the  nostrils  and  the  upper  lip,  should  always  be  regarded 
with  suspicion.  It  may  mean  nothing  more  than  a  cold  in  the  head, 
but  not  infrequently  indicates  diphtheria. 

Evidences  of  Sore  Throat. — Evidences  of  sore  throat,  such  as  swelling 
of  the  neck  and  difficulty  in  swallowing,  are  of  importance.  They 
may  mean  nothing  but  tonsillitis,  but  are  not  infrequently  manifestations 
of  diphtheria  or  scarlet  fever. 

Coughs. — It  is  very  important  to  notice  whether  children  are  cough- 
ing or  not,  and  what  is  the  character  of  the  cough.  In  most  cases, 
of  course,  the  cough  merely  means  a  simple  cold  or  slight  bronchitis. 


Suggestions  to  Teachers  and  School  Physicians     231 

A  spasmodic  cough,  that  is,  a  cough  which  occurs  in  paroxysms  and  is 
uncontrollable,  very  frequently  indicates  whooping-cough.  A  croupy 
cough,  that  is,  a  cough  which  is  harsh  and  ringing,  may  indicate  the 
disease  diphtheria.  A  painful  cough  may  indicate  disease  of  the  lungs, 
especially  pleurisy  or  pneumonia.  A  long-continued  cough  may  mean 
tuberculosis  of  the  lungs. 

Vomiting. — Vomiting  usually,  of  course,  merely  means  some  diges- 
tive upset.  It  may,  however,  be  the  inidal  symptom  of  many  of  the 
acute  diseases,  and  is  therefore  of  considerable  importance. 

Frequent  Requests  to  go  out. — Teachers  are  too  much  inclined  to 
think  that  frequent  requests  to  go  out  merely  indicate  restlessness  or 
perversity.  They  often,  however,  indicate  trouble  of  some  sort,  which 
may  be  in  the  bowels,  kidneys  or  bladder;  therefore,  they  should  always 
be  reported  to  the  physician. 

The  Teeth 

Unclean  mouths  promote  the  growth  of  disease  germs,  and  cavities 
in  the  teeth  are  centers  of  infection.  Pus  from  diseased  teeth  seriously 
interferes  with  digestion,  and  poisons  the  system.  It  causes  a  lowering 
of  vitality  and  renders  mental  effort  dif&cult.  Diseased  teeth,  tempo- 
rary as  well  as  permanent,  are  frequently  the  cause  of  abscesses,  and 
should  be  carefully  watched  and  treated. 

Irregularities  of  the  teeth,  especially  those  which  make  it  impossible 
to  close  the  teeth  properly,  lead  to  faulty  digestion,  to  mouth-breathing, 
and  to  other  diseases  and  evils  which  an  insufficient  supply  of  oxygen 
produces. 

The  first  permanent  molars  are  perhaps  the  most  important  teeth 
in  the  mouth,  and  are  the  most  frequently  neglected,  because  they  are 
so  often  mistaken  for  temporary  teeth.  (It  should  be  remembered 
that  there  are  twenty  temporary  teeth,  ten  in  each  jaw,  and  that  the 
teeth  that  come  at  about  the  sixth  year  immediately  behind  each  last 
temporary  tooth — four  in  all — are  the  first  permanent  molars.) 

The  teacher  should  be  on  the  lookout  for  pain  or  swelling  in  the  face. 
When  the  child  keeps  the  mouth  constantly  open,  an  examination  of 
the  teeth  should  be  made.  When  symptoms  of  indigestion  occur,  or 
physical  weakness  or  mental  dullness  is  observed,  the  teeth  should  be 
inspected.     It  should  be  remembered  that  disease  of  the  ears,  disturb- 


232  Medical  Inspection  of  Schools 

ances  of  vision  and  swelling  of  the  glands  of  the  neck  may  be  caused 
by  diseased  teeth. 

It  should  be  known  that  decay  of  the  teeth  is  caused  primarily  by 
the  fermentation  of  starchy  foods  and  sugars,  and  that  the  greatest 
factor  in  preventing  dental  caries  is  the  removal  of  food  particles  by 
frequent  brushing.  Children  should  be  prevented  from  eating  crackers 
and  candy  between  meals,  and  when  possible  the  teeth  should  be  cleaned 
after  eating.  Inspection  of  the  teeth  by  a  dentist  should  be  made  at 
least  once  in  six  months. 

Nervous  Troubles  and  Mental  Defects 

Teachers  and  medical  inspectors  of  the  schools  should  investigate 
children  who  show  certain  physical  and  mental  symptoms.  Especially 
should  they  take  notice  of  the  presence  of  these  symptoms  in  a  child 
who  did  not  formerly  show  them.  The  most  important  of  these  are  the 
following: — 

I. — Restlessness  and  inabiUty  to  stand  or  sit  quietly,  in  a  previously 
quiet  child,  especially  if  to  this  is  added  irritability  of  temper  and  loss 
of  self-control,  as  shown  by  crying  for  trifles,  or  inability  to  keep  the 
attention  fixed. 

There  may  also  be  present  quick,  twitching  movements  of  the  mus- 
cles of  the  trunk,  face,  and  especially  of  the  hands,  fingers,  arms  or  legs. 
If  severe,  these  may  cause  the  child  to  drop  things,  render  its  work 
awkward,  or  interfere  with  buttoning  the  clothes,  writing  or  drawing. 
Such  children  are  often  scolded  for  being  inattentive  or  careless. 

These  symptoms  are  the  slighter  ones  of  chorea  (St.  Vitus'  dance). 
"With  these  should  not  be  confounded  other  forms  of  twitching  of  mus- 
cles, such  as  the  blinking  of  the  eyelids,  the  slower  twitching  movements 
of  the  face  or  shoulders,  or  other  parts  of  the  body,  often  called  habit 
spasms,  which  may  be  due  to  defects  of  vision,  adenoid  growths  or 
other  reflex  causes.  These  latter  cases  do  not  usually  need  to  be  with- 
drawn from  school  work,  though  often  requiring  treatment;  while  the 
former  class  should  be  removed  from  school  at  once,  both  for  the  child's 
sake,  and  to  prevent  an  epidemic  of  imitative  movements,  such  as 
sometimes  occurs. 

II. — Another  class  of  symptoms  requiring  investigation  are  repeated 
faintings,  especially  if  the  child's  lips  become  blue;  attacks,  often  only 


Suggestions  to  Teachers  and  School  Physicians    233 

momentary,  in  which  the  child  stares  fixedly  and  does  not  reply  to 
questions,  or  in  which  he  suddenly  stops  speaking  or  whatever  he  is 
doing,  and  is  unaware  of  what  is  going  on  about  him.  These  lapses 
of  consciousness  may  be  accompanied  also  by  rolling  up  of  the  eyes, 
drooling,  or  unusual  movements  of  the  lips,  and  often  appear  like  a 
"choking"  attack. 

Sudden  attacks  of  senseless  movements  of  various  sorts,  such  as 
twisting  and  pulling  at  the  clothes  or  handkerchief,  fumbling  aimlessly 
at  the  desk,  especially  if  there  is  no  recollection  afterwards  of  what  was 
done,  are  often  another  expression  of  the  same  conditions. 

Such  attacks,  particularly  if  repeated  at  varying  intervals,  even 
when  not  accompanied  by  complete  loss  of  consciousness,  are  frequently 
as  characteristic  of  epilepsy  as  the  severe  convulsions. 

Epileptic  convulsions  usually  involve  the  entire  body  in  sharp 
jerking  movements,  with  blueness  of  the  face  or  lips,  complete  loss  of 
consciousness,  and  are  usually  followed  by  a  period  of  sleep  or  drowsi- 
ness, and  are  frequently  accompanied  by  frothing  at  the  mouth,  biting 
of  the  tongue,  and  occasionally  by  wetting  or  soiling  of  the  clothes. 

Another  class  of  convulsions  is  the  hysterical,  which  are  often  difl&cult 
to  distinguish.  The  hysterical  convulsion,  however,  differs  from  the 
epileptic  in  the  following  respects.  The  hysterical  patient  often  shouts, 
cries  or  raves,  not  only  previous  to  but  frequently  throughout  the  attack, 
and  is  often  able  to  reply  to  questions  during  the  convulsion.  The 
epileptic  gives  a  single  cry,  immediately  followed  by  unconsciousness 
and  the  spasm.  The  movements  in  the  hysterical  convulsion  are  often 
accompanied  by  bowing  of  the  body  backward,  and  very  frequently 
simulate  intentional  or  voluntary  movements,  such  as  tearing  the  hair, 
pulling  at  the  clothes,  and  such  things;  while  the  epileptic  movements 
are  characterized  by  their  jerking  or  twitching  character.  The  hysterical 
patient,  also,  in  place  of  a  convulsion,  may  strike  an  attitude,  such  as  of 
fear  or  entreaty,  often  accompanied  by  raving  or  singing.  This  again 
may  follow  the  convulsion,  taking  the  place  of,  and  strikingly  contrasted 
with,  the  almost  invariable  sleep  of  the  epileptic,  which  is  almost  never 
seen  in  hysteria.  Hysterical  patients  if  they  fall  seldom  injure  them- 
selves by  the  fall,  as  epileptics  frequently  do.  Biting  the  tongue  almost 
invariably  indicates  an  epileptic  seizure,  as  does  wetting  or  soiling  the 
clothes  when  it  occurs. 


234  Medical  Inspection  of  Schools 

Cases  of  epilepsy,  whether  mild  or  severe,  require  treatment,  and 
advice  as  to  whether  they  should  be  removed  from  school.  Many 
cases  do  not  require  to  be  withdrawn  from  school,  and  are  benefited  by  its 
discipline. 

III. — Excessive  nerve  fatigue,  which  is  shown  by  irritability  or 
sleeplessness,  may  indicate  a  neurasthenic  condition,  that  is,  a  threatened 
nervous  breakdown.  Such  symptoms  may  be  due  to  irregular  habits, 
want  of  proper  sleep,  lack  of  suitable  food,  poor  hygienic  conditions,  or 
simply  from  the  child  being  pushed  in  school  beyond  its  physical  or 
mental  capacity. 

Excessive  fear  or  morbid  ideas,  bashfulness,  undue  sensitiveness, 
causeless  fits  of  cr^ang,  morbid  introspection  and  suspiciousness  may 
also  be  symptoms  of  a  neurasthenic  condition,  and  call  for  investiga- 
tion, and  for  the  teacher's  sympathy  and  winning  of  the  child's  confi- 
dence, to  prevent  developments  of  a  more  serious  nature. 

This  nerve  fatigue  may  result  in  a  child  being  unable  for  the  time 
being  to  keep  up  in  its  work  in  school. 

Forgetfulness,  loss  of  interest  in  work  and  play,  desire  for  solitude, 
untidiness  in  dress  or  person,  and  like  changes  of  character,  are  some- 
times incidental  to  the  period  of  puberty. 

IV. — Mentally  defective  children  in  the  public  schools  exhibit  cer- 
tain common  characteristics.  The  essential  evidence  of  mental  defect 
is  that  the  child  is  persistently  unable  to  profit  by  the  ordinary  methods 
of  instruction,  as  shown  by  lack  of  progress  or  failure  of  promotion 
through  lack  of  capacity.  After  one,  two  or  three  years  in  school, 
they  are  either  not  able  to  read  at  all,  or  they  have  a  very  small  and 
scanty  vocabulary.  One  of  the  most  constant  and  striking  peculiarities 
is  the  feebleness  of  the  power  of  voluntary  attention.  The  child  is 
unable  to  fix  his  attention  upon  any  exercise  or  subject  for  any  length  of 
time.  The  moment  his  teacher's  direction  is  withdrawn,  his  attention 
ceases. 

These  children  are  easily  fatigued  by  mental  effort,  and  lose  interest 
quickly.  They  are  not  observant.  They  are  often  markedly  back- 
ward in  number  work.  They  are  especially  backward  in  any  school 
exercise  requiring  judgment  and  reasoning  power.  They  may  excel 
in  memory  exercises.  They  usually  associate  and  play  with  children 
younger  than  themselves.     They  have  weak  will-power.     They  are 


Suggestions  to  Teachers  and  School  Physicians     235 

easily  influenced  and  led  by  their  associates.  These  children  may  be 
dull  and  listless,  or  restless  and  excitable.  They  are  often  wilful  and 
disobedient,  and  liable  to  attacks  of  stubbornness  and  bad  temper. 
The  typical  "incorrigible"  of  the  primarv'  grades  often  is  a  mentally 
defective  child  of  the  excitable  type.  They  are  often  destructive. 
They  may  be  cruel  to  smaller  children.  They  are  often  precocious 
sexually.  They  may  have  untidy  personal  habits.  Certain  cases 
with  only  slight  intellectual  defect  show  marked  moral  deficiency 

The  physical  inferiority  of  these  defective  children  is  often  plainly 
shown  by  the  general  appearance.  There  is  generally  some  evidence 
of  defect  in  the  figure,  face,  attitudes  or  movements.  They  seldom 
show  the  physical  grace  and  charm  of  normal  childhood.  The  teeth 
are  apt  to  be  discolored  and  to  decay  early. 

It  is  a  most  delicate  and  painful  task  to  tell  a  parent  that  his  child 
is  mentally  deficient.  This  duty  should  be  performed  with  the  greatest 
tact,  kindness  and  sympathy.  It  would  be  a  great  misfortune  for  the 
school  physician  and  teacher,  as  well  as  for  the  child,  to  designate  a 
pupil  as  feeble-minded  who  was  only  temporarily  backward. 

Temporar}'  backwardness  in  school  work  may  be  due  to  removable 
causes,  such  as  defective  vision,  impaired  hearing,  adenoid  growths  in 
nose  or  throat,  or  as  the  result  of  unhappy  home  conditions,  irregular 
habits,  want  of  proper  sleep,  lack  of  suitable  food,  bad  hygienic  condi- 
tions, etc.  Great  care  must  always  be  used  in  order  not  to  confound 
cases  of  permanent  mental  deficiency  with  cases  of  temporary'  back- 
wardness in  school  work,  due  to  the  causes  mentioned  above,  or  those 
described  under  the  head  of  excessive  nervous  fatigue. 

In  some  cases,  where  the  existence  of  mental  defect  is  in  doubt, 
accurate  information  is  usually  to  be  obtained  in  the  early  histor}'  of 
the  child.  The  time  of  first  "taking  notice,"  the  time  of  recognition 
of  the  mother,  that  of  beginning  to  sit  up,  to  creep,  to  stand,  to  walk 
and  to  talk  should  be  learned.  Marked  delay  in  development  in  these 
respects  is  usually  found  in  all  pronounced  cases  of  mental  deficiency. 

It  may  be  found  useful  to  require  teachers  to  refer  at  stated  inter\'als 
to  the  medical  inspectors  for  examination  all  children  who,  without 
obvious  cause,  such  as  absence  or  ill  health,  show  themselves  imable  to 
keep  up  in  their  school  work,  who  are  unable  to   fix  their  attention,  or 


236  Medical  Inspection  of  Schools 

are  incorrigible, — though  it  does  not  follow  that  all  such  cases  have 
either  physical  or  mental  defects. 

School  Hygiene 

The  school  physician  should  notice  the  ventilating,  lighting  and  heat- 
ing of  the  rooms,  and  the  location  of  the  source  of  water  supply  with 
reference  to  possible  pollution.  In  case  pollution  of  the  water  supply  is 
suspected,  apphcation  should  be  made  to  the  State  Board  of  Health 
for  an  examination  of  the  water.  The  general  cleanliness  of  the  school- 
room is  of  importance,  and  the  admission  of  sunlight  when  possible  is 
desirable. 

The  Closets. — The  school  physician,  accompanied  by  the  janitor 
of  the  school,  should  inspect  the  toilet  rooms,  to  see  if  the  floors  are  clean 
and  dry,  that  the  bowls  of  the  closets  are  properly  emptied  and  kept 
clean.  (If  outhouses  are  used,  a  large  supply  of  earth  will  aid  in  keeping 
the  place  in  a  sanitary  condition.)  A  few  simple  directions  as  to  the 
cleanliness  of  the  room  should  be  posted  in  the  closets. 

Cups. — The  use  of  one  drinking  cup  for  a  number  of  children  is  to  be 
condemned,  as  tending  to  spread  the  infectious  diseases  from  child  to 
child.  The  so-called  hygienic  drinking  fountain,  now  in  more  or  less 
general  use  in  progressive  cities  and  towns,  is  to  be  recommended  where 
running  water  is  available.  If  there  is  no  running  water,  each  child 
should  use  his  own  cup. 

School  Furniture 

Any  proper  sort  of  school  furniture  should  furnish  a  seat  of  such 
height  that  the  feet  will  rest  easily  on  the  floor.  It  should  have  a  desk 
high  enough  not  to  touch  the  knees.  It  should  have  a  desk  low  enough 
for  the  arm  to  rest  on  comfortably  without  much  raising  of  the  elbow; 
not,  however,  so  low  that  the  scholar  must  bend  down  to  write  on  it. 

The  seat  should  be  near  enough  so  that  the  scholar  may  reach  the 
desk  to  write  on  it  without  leaning  forward  more  than  a  Uttle,  and  without 
entirely  losing  the  support  of  the  backrest.  The  seat  should  not  be  so 
close  as  to  press  against  the  abdomen  nor  near  enough  to  interfere 
with  easy  rising  from  the  seat.  This  means  a  distance  of  ten  and  one- 
half  to  fourteen  and  one-half  inches  from  the  edge  of  the  desk  to  the 


Suggestions  to  Teachers  and  School  Physicians     237 

seat  back;  it  also  means  that  the  seat  must  not  project  under  the  desk 
more  than  an  inch  at  most. 

The  seat  should  have  a  back-rest  that  will  support  the  "small  of 
the  back"  properly,  without  having  the  scholar  lean  back  excessively. 
Whether  it  also  supports  the  rest  of  the  back  or  not  is  of  small  conse- 
quence; support  of  the  back  carried  up  to  the  level  of  the  shoulder 
blades  is  likely  to  do  more  harm  than  good. 

These  are  given  as  the  minimum  requirements.  Whether  or  not 
regular  adjustable  furniture  is  in  use,  we  should  not  be  content  with 
less  than  the  accomplishment  in  one  way  or  another  of  these  primitive 
adjustments.  More  accurate  adjustment  is  desirable,  and  less  care  in 
adjusting  would  be  hard  to  justify,  in  the  light  of  our  present  knowledge 
of  the  results  of  faulty  attitude. 


Appendix  II 


A  TYPICAL  SET  OF  EUROPEAN  BLANKS  AND  FORMS 

(Translations  of  those  used  in  Briinn,  Austria) 

FORM  I 

Notice  to  Parents 
As  a  result  of  the  physical  examination  of  your  child 

,  which 

examination  was  made  in  accordance  with  the  provisions 
of  the  town  council  of  the  city  of  Briinn,  it  has  been  found 
that  he  (she)  is  suffering  from 

In  the  interests  of  your  child,  as  also  for  the  welfare  of 
the  school, 


is  urgently  required. 

Briinn, ig 

Medical  Inspector 
To 


238 


A  Typical  Set  of  European   Blanks  and  Forms    239 


FORM  II 
Notice  to  Parents 


To 

Mr.  (Mrs.). 


At    the    recent    medical    examination    made    of    your 
child , 

the  hair  was  found  to  contain  vermin. 

In  the  interests  of  your  child,  of  your  family,  and  of 
the  school,  a  thorough  cleansing  is  urgently  requested. 


By  Order  of  the  City  Council: 
Briinn, 19 . 


Note:  The  cutting  of  the  hair  is  recommended;  or  rub- 
bing the  head  with  petroleum  (taking  care  of  the  eyes 
and  of  proximity  to  a  light),  then  enveloping  the  head 
in  a  closely  fitting  cap  for  twelve  hours,  thereafter 
washing  with  warm  water  and  soap;  or  saturating 
the  hair  with  a  fatty  substance,  frequent  combings, 
and  rubbing  with  vinegar  to  eliminate  the  nits. 


240 


Medical  Inspection  of  Schools 


FORM  m 


Health  Report 


of son  (daughter)  of 

Born I 

Vaccinated i School since i . 

Revaccinated i 


Date  and  School 
Year. 

General 
Constitu- 
tion. 

Ht. 

CM. 

Wt. 

KG. 

Size 

OF 

Chest 

CM. 

Chest  and 
Abdomen 
(Tuberculo- 
sis AND  Her- 
nia, etc.). 

Skin  Dis- 
eases 
(Parasites). 

Spine  and 

Extremities 

(Scrofula, 

Rickets.) 

I 

Winter 
Summer 

11 

Winter 
Summer 

III 

Winter 
Summer 

IV 

Winter 
Summer 

\T  i  Winter 
'      Summer 

VI 

Winter 
Summer 

VII 

Winter 
Summer 

VIII 

Winter 
Summer 

A  Typical  Set  of  European  Blanks  and  Forms    241 


(Reverse  of  Form  III) 


Date  and  School 
Year. 

Eyes 
AND  Eye- 
sight. 

Ears 

AND 

Hearing. 

Mouth, 

Nose  and 

Speech. 

Recommen- 
dations for     Notices 
Treatment           to 
IN  School.      Parents. 
Remarks. 

Remarks'op 
Teacher 

(Illnesses, 
Number  op 
Hours  Ab- 
sent, ETC. 

Instruction 
III,  7). 

Winter 
•  ■  I  Summer 

1 

IT    Winter 
A  1    Summer 

III     Winter 
i  *  A  '  Summer 

ly;  Winter 
A  V     Summer   j 

V 

Winter 
Summer 

y  T    Winter 
*  A    Summer 

y  T  T    Winter 
'All  Summer 

1 

VIII 

Winter 
Summer 

16 


242 


Medical  Inspection  of  Schools 


Pi 

o 


I 

4» 

H 


o 

(0 

00 


o 


-4-> 

d 
o 


o 
o 

u 


Re- 
marks 

of 
Teach- 
er. 

Recommenda- 
tions AS  to 
Treatment  in 
School  (Physi- 
cian's Certifi- 
cate).  Remarks. 

«  ,rtQ 
H  W  u 
P  S  W 

5:1  a 

< 

w 

w  ><  „• 
P.  Q  S 

Para- 
sites. 
Skin 
Dis. 

Chest 
and 

Abdo- 
men. 

z 
o 

H 

D 

H 

i-i 
< 
Pi 

w 
z 

H 

o 

S 

3 
1 

o 
o 
O 

O 
O 

c5^ 

O 

o 

A  Typical  Set  of  European  Blanks  and  Forms    243 


o 
o 


z 

n 

o5 

< 
0 

No.  OF 

Indi- 
vidual 
Examin- 
ations. 

No.  OF 
Pupils 
Exam- 
ined. 

0  y,   . 
0  3  « 

No.  OF 
Visits 

BY 

Physi- 
cians. 

1 

0 

2. 

0 

m 

244 


Medical  Inspection  of  Schools 


FORM  VI 


Physician's  Report 


Born School . 


.Street. 


General  Constitution  Mentality 
Chest  Organs  (Tuberculosis) 
Abdominal  Organs  (Hernia) 
Spine  and  Extremities 
Skin  (Parasites) 
Eyes,  Eyesight 
Ears,  Hearing 
Mouth,  Nose  and  Speech 
Remarks 

Physician's   Recommendations   regard- 
ing Instruction 


Briinn, 19. . 


Practising  Physician 


Note. — Physicians  are  requested  to  make  out  the  report  as  carefully 
as  possible.  The  first  section,  "General  Constitution,"  must 
always  be  filled  out,  and  according  to  the  category  of  "good," 
"medium,"  and  "bad,"  bracketing  (chlorosis,  tuberculosis,  etc.). 
The  other  sections  need  only  be  filled  out  in  case  of  symptoms. 

A  detailed  statement  in  the  section,  "Remarks,"  is  particu- 
larly desired  when  questions  arise  as  to  absences  of  the  child  or 
questions  of  excuses  from  lessons  and  from  physical  training. 


FORM  VII 


Memorandum  Blank 


With  Reference  to  Unhygienic  Conditions  found  in  School  Houses  by 
Medical  Inspectors 


Briinn, 19 


Medical  Inspector 


A  Typical  Set  of  European  Blanks  and  Forms    245 

Questions  to  Parents  or  Guardians 
In  the  interests  of  the  pupil,  so  that  due  consideration  may  be  ac- 
corded to  him  in  school,  it  is  requested  that  careful  answers  be  given. 


Name  of  Pupil 


During  what   years  of   life   did    sickness   occur? 
Name  the  illnesses. 


Did  you  observe  continued  ill  effects  of  such  sick- 
ness ?     What  effects  and  since  when  ? 


Has  the  child  sustained  injuries  of  lasting  conse- 
quence ?     When,  and  what  injuries  ? 


When  did  the  child  (a)  learn  to  walk,  (b)  learn  to 
talk? 


Has  the  child  weak  eyes,  or  is  he  nearsighted? 
Since  when  and  what  is  the  cause  ? 


Has  the  child  difficulty  in  hearing?     Since  when 
and  what  was  the  cause  ? 


Is  the  child  suffering  from  other  defects  or  weak- 
nesses? (Frequent  headaches,  nose  bleeding, 
lassitude,  frequent  loss  of  appetite,  convulsions, 
nervous  irritability,  difficulties  in  speech,  psychic 
peciiUarities.) 


Has  puberty  been  reached?  Since  when?  Are 
the  periods  regular?  Are  there  difficulties? 
WTiat  difficulties  ? 


Does  the  child  regularly  partake  of  alcohol? 
Does  he  drink  beer,  wine,  tea  with  rum,  and  if 
so,  in  what  quantities  ? 


A  regular  system  of  medical  inspection  has  been 
introduced  into  the  school.  Parents  or  guar- 
dians are,  therefore,  requested  to  indicate  clearly 
as  to  whether  they  grant  or  refuse  their  consent 
for  the  examination  of  the  child  by  the  school 
physician. 


Briinn, 


Signature 


246 


Medical  Inspection  of  Schools 


(Individual  Report  Giving  Results  of  Semi-Annual  Physical  Examinations  During 
the  School  Life  of  Eight  Years.) 


Health  Report 
Name Born. . . 


Vaccinated 


Class 

I 

II 

m 

IV 

V 

VI 

VII 

vni 

Terms 

I 

2 

I 

2 

I 

2 

I 

2 

I 

2 

I 

2 

I 

2 

I 

a 

Examined  (Date) 
General  Condition  of  Body 
Height  in  cm. 
Weight  in  kg. 

I. 

Condition 

of  the 
Body  and 
the  Blood 

1.  Anaemia 

2.  Chlorosis 

3.  Scrofula 

4.  Enlarged  Glands 
5- 

n. 

Osseous 
Structure 

1.  Malformation  of  Skull 

2.  Malformation  of  Sternum 

3.  Scoliosis 

4.  Deformities  of  Limbs 
5- 

m. 

Condition 
of  Bones, 

Joints, 
and 

Muscles 

1.  Chronic   Inflammation   of   the 

Bones 

2.  Chronic  Inflammation  of  the 

Joints 

3.  Rachitis 

4.  Wry-neck 
5- 

IV. 
Skin 

1.  Eczema 

2.  Psoriasis 

3.  Furunculosis 

4.  Prurigo 
5- 

V. 
Mouth, 
Throat, 

Nose 

1.  Adenoids 

2.  Ozena 
3- 

VI. 

Condition 
of  Lungs 

1.  Asthma  bronchiale 

2.  Tuberculosis 

3.  Chronic  Catarrh 

VII. 

Condition 

of    the 

Heart 

1.  Funktionelle 

2.  Malformation,     or     defective 

heart 
3- 

A  Typical  Set  of  European  Blanks  and  Forms    247 


(Reverse  of  Health 

Report) 

Class 

I 

n 

m 

IV 

V 

VI 

VII 

vin 

Terms 

1 

2 

2 

I 

3 

I 

2 

I 

2 

I 

2 

I 

2 

I 

3 

vni. 

Abdominal 
Organs 

1.  Chronic  Catarrh   of   Stomach 

and  Intestines 

2.  Hemorrhage  from  Stomach 

3.  Nycturia 
4- 

5- 

IX. 

Eyesight 

1.  Myopia 

2.  Hypermetropia 

3.  Weak  Eyesight 

4.  Twitching  of  the  Eyes 

5.  Strabismus 
6. 

X. 

Diseases 

of    the 

Eyes 

1.  Chronic  Inflammation   of   the 

Conjunctiva 

2.  Chronic  Inflammation   of   the 

Cornea 

3.  Chronic  Inflammation  of  the 

Eyelids 

4.  Trachoma 

5.  Scars  and  Spots 
6. 

XI. 

Hearing 

I.  Ability  to  hear  WTiisper 
2. 

xn. 

Diseases 
of  the  Ear 

I.  Discharge  from  Ears 
2. 

XIII. 

Speech 

1.  Stammering 

2.  Stuttering 

xrv. 

Defects  of 
Develop- 
ment 

1.  Defective  Palate 

2.  Inguinal  Hernia 

3.  Umbihcal  Hernia 

4.  Goitre 

XV. 

Nervoiis 
System 

1.  Con\'ulsions 

2.  Epilepsy 

3.  Paralysis 
4- 

5.  Ataxia 

6.  Chorea 

J.  Abnormal  Reflexes,  Twitchings 
8. 

XVI. 
Psychic 
Peculiar- 
ities 

1.  Unusual  Irritability 

2.  Particular  Inclinations 
3- 

XVII. 
Parasites 

I.  Scabies 
a.  Pediculosis 
3- 

Condition 
of  Teeth 

Develop- 
ment 

Remarks.     Absences  from   school  on  account 
of  illness.     Mention  them   and   give   dates 
and  periods  of  each  sickness. 

248  Medical  Inspection  of  Schools 

FORM  I  (Dental) 

Briinn, 190 

Name: Pupil  in  class 

of  school ,  residing  at 

requires  prompt  dental  treatment.  If  it  meets  with  your 
consent  to  have  him  (her)  undergo  such  treatment,  it  is 
requested  that  you  signify  your  willingness  by  signature. 
Treatment  is  conducted  at  the  expense  of  the  city. 


Medical  Inspector  School  Principal 

Affirmation 
I  hereby  testify  my  wiUingness  to  have  my  child ........ 

.  ^  •«  >.  ^. .-. . . .  -  - — undergo  dental  treatment. 

Signature: 


A  Typical  Set  of  European  Blanks  and  Forms    249 

(Reverse  of  Form  I — Dental) 

Care  of  the  Mouth  and  Teeth 

Food  well  chewed  is  half  digested.  Badly  kept  teeth 
hinder  mastication;  they  create  a  disagreeable  odor,  and 
are  often  the  cause  of  interferences  with  health.  Pieces  of 
food  lodge  and  decay  in  carious  teeth;  and  disease  germs 
are  found  in  the  oral  cavity. 

Therefore,  from  the  standpoint  of  breathing  and  from 
that  of  good  digestion,  the  hygiene  of  the  mouth  is  most 
essential.  For  this  reason  the  mouth  and  teeth  should  be 
rinsed  daily,  in  the  morning  and  in  the  evening,  with  clean, 
lukewarm  water.  The  teeth  and  gums  should  be  cleansed 
with  a  clean,  moistened  brush,  using  as  a  tooth  powder 
finely  ground  chalk,  and  by  moving  the  brush  up  and 
down.  Finally  the  mouth  and  throat  should  be  rinsed 
throroughly  with  water. 

Food  eaten  very  cold  or  very  hot,  that  which  is  too 
sweet  or  too  sour,  as  well  as  food  highly  spiced,  is  injurious 
to  the  teeth. 

The  moistening  of  postage  stamps,  envelopes,  or  ink 
spots  with  the  tongue;  the  putting  of  the  fingers,  of  play- 
things or  any  other  objects  into  the  mouth;  the  insertion 
of  hard  substances,  such  as  a  fork,  penknife,  pen,  pin,  etc., 
between  the  teeth  may  cause  great  damage.  None  but 
wooden  or  quill  toothpicks  should  be  used. 

In  the  case  of  a  diseased  tooth,  the  sooner  a  dentist  is 
consulted,  the  sooner  is  it  possible  to  remove  the  difficulty. 


250  Medical  Inspection  of  Schools 

FORM  II  (Dental) 

No Briinn 190 

ToDr 

Dentist 

in  Briinn. 

Upon  consent  having  been  obtained  from  the  parents  of 

pupil  in  class ,  school 

located  at ,   for  dental  treatment  of 

their  child,  you  are  hereby  requested  to  undertake  such 
treatment  and  to  make  appointments. 

City  Physician 


(Reverse  of  Form  II  same  as  reverse  of  Form  I) 


Appendix  III 


RULES   ISSUED   TO    MEDICAL   INSPECTORS   OF   SCHOOLS 

IN  CHICAGO,   ILL.,   DETROIT,    MICH.,  AND 

SPRINGFIELD,  MASS. 

I.  Rules  for  Medical  Inspectors  and  School  Medical  Inspectors, 
Department  of  Public  Health,  City  of  Chicago 

Medical  Inspectors  should  familiarize  themselves  with  the  City 
Health  Ordinances.     (Copies  can  be  had  by  applying  to  the  Secretary.) 

Beginning  at  9  o'clock  Medical  Inspectors  wiU  call  daily  at  the 
schools  assigned  them,  and  request  principals  to  have  all  pupils  in  readi- 
ness for  examination  who  have  been  absent  from  school  for  four  con- 
secutive days.  The  principal  will  also  refer  to  the  Inspector  any  pupils 
in  school  who  are  suspected  to  be  suffering  from  infectious  or  contagious 
diseases. 

The  examinations  will  be  made  at  the  school. 

The  principal  of  school  should  have  aU  children  to  be  examined 
sent  to  a  room  by  themselves  where  the  other  pupils  will  not  come  in 
contact  with  them,  and  where  the  school  inspector  can  examine  them. 

Inspection  is  to  be  made  in  reference  to  communicable  diseases 
and  the  vaccinal  status  of  pupils  only. 

Examinations  are  to  be  made  for  the  following  diseases:  Scarlet 
fever,  diphtheria,  measles,  rothein,  smallpox,  chickenpox,  tonsillitis, 
pediculosis,  ringworm,  impetigo  contagiosa  or  other  transmissible 
diseases  of  the  skin,  scalp  and  eye.  Tuberculosis,  when  thought  to 
be  far  enough  advanced  to  be  a  menace  to  the  public  health,  must  be 
reported  to  the  Chief  Medical  Inspector  before  excluding  the  pupil  from 
school. 

Scarlet-fever  cases  must  not  be  allowed  to  return  to  school  until 
all  desquamation  is  completed,  and  there  is  an  entire  absence  of  dis- 

251 


252  Medical  Inspection  of  Schools 

charge  from  ears,  nose,  throat  or  suppurating  glands  and  the  child  and 
premises  are  disinfected.  This  requires  at  least  six  weeks — severe 
cases  eight  weeks  or  longer. 

Diphtheria  cases  must  be  excluded  until  two  throat  cultures  made 
upon  two  consecutive  days  show  absence  of  the  Klebs-LoefBer  bacilli. 
Those  exposed  to  diphtheria  should  be  excluded  one  week  from  last 
exposure. 

Measles  cases  are  very  infectious  in  the  early  stages,  and  must  be 
excluded  at  least  three  weeks  and  longer  if  there  is  present  bronchitis, 
inflammation  of  the  throat,  nose  or  abscess  of  the  ear.  Those  exposed 
to  measles  should  be  excluded  two  weeks  from  date  of  last  exposure. 

Whooping  Cough:  Cases  should  be  excluded  until  after  the 
spasmodic  stage  of  cough — usually  about  eight  weeks.  Whooping 
cough  is  very  infectious  in  the  early  stages  of  the  disease.  Those  ex- 
posed to  whooping  cough  should  be  excluded  two  weeks  from  date  of 
last  exposure. 

Mumps :  Exclude  ten  days  after  all  swelling  has  subsided.  Those 
exposed  to  mumps  should  be  excluded  three  weeks  from  date  of  last 
exposure. 

Chickenpox:  Exclude  until  scabs  are  all  off  and  skin  smooth — 
two  to  three  weeks,  according  to  the  severity  of  the  attack. 

Rothein,  German  Measles;  Exclude  from  school  two  weeks. 
Those  exposed  to  rothein  must  be  excluded  from  school  three  weeks 
from  date  of  last  exposure. 

Cases  of  tonsillitis  must  be  excluded  on  the  clinical  evidence  alone, 
and  throat  cultures  made  for  further  diagnosis. 

Cases  presenting  suspicious  throats,  but  not  definite  evidence  of 
disease  clinically,  must  have  throat  cultiu-es  made,  allowed  to  return 
to  their  classes  until  the  cultures  have  been  examined,  and  only  excluded 
in  case  the  bacteriologic  examination  shows  exclusion  to  be  necessary. 

In  making  inspections  care  must  be  used  to  disturb  the  child  as 
little  as  possible,  and  throat  cultures  are  to  be  made  only  when  good  rea- 
son therefor  exists. 

In  making  throat  examinations,  the  wooden  tongue  depressors 
supplied  must  be  used,  to  the  exclusion  of  all  other  tongue  depressors. 
Each  tongue  depressor  must  be  used  only  once  and  then  burned.  Asep- 
tic methods  must  be  employed  in  all  examinations. 


Rules  Issued  to  Medical  Inspectors  253 

If  a  child  is  excluded,  brief  but  sufficient  reason  therefor  must  be 
written  on  the  exclusion  card. 

Inspectors  are  forbidden  to  make  any  suggestions  as  to  the  treat- 
ment or  management  of  pupils  who  are  sick.     This  is  imperative. 

Children  recovering  from  measles,  whooping  cough,  mumps,  chicken- 
pox,  scarlet  fever,  diphtheria  and  smallpox — must  not  re-enter  school 
without  a  permit  from  the  Department  of  Health. 

When  a  pupil  is  taken  sick  with  an  infectious  disease  in  a  school- 
room, the  pupils  in  the  room  must  be  dismissed,  and  the  room  disinfected. 

If  smallpox  is  found  in  the  eruptive  stage,  the  child  can  be  taken  to 
his  home,  if  near,  and  there  isolated  until  the  ambulance  arrives,  or 
isolate  in  the  room  where  found.  In  doing  this  no  one  should  be  allowed 
to  come  near  the  infected  child. 

Children  properly  vaccinated  who  have  been  exposed  to  small- 
pox need  not  be  excluded  from  school.  Those  exposed  and  not  vacci- 
nated must  be  excluded  twenty  days. 

Pupils  living  in  apartment  buildings,  where  an  infectious  disease 
exists,  should  be  excluded  from  school  by  the  principal.  A  visit  to  the 
building  by  the  Inspector  will  determine  who  can  return  to  school  with 
safety.  It  depends  upon  the  construction  of  the  building  and  the 
habits  of  the  inmates  whether  it  is  safe  to  let  any  from  the  building 
continue  in  school.  The  Inspector  must  be  the  judge.  Usually  if 
families  use  the  same  entrance  there  is  some  risk,  and  yet  a  case  can 
be  so  well  isolated  and  cared  for  that  all  others  in  the  building  are  safe. 
A  visit  to  the  building  is  necessary  to  determine  this. 

All  cases  of  infectious  diseases  coming  under  the  observation  of  the 
Inspector  which  are  not  properly  safeguarded  should  command  his 
attention. 

Give  proper  instructions  to  the  family,  leave  the  Department  cir- 
cular applicable  to  the  case,  and  take  any  other  measures  necessary 
to  protect  the  public  health.  Investigate  all  suspected  cases  of  infectious 
diseases  in  your  territory  and  take  proper  measures  for  safeguarding 
against  the  spread  of  infection.  Make  daily  reports  to  the  Chief  ISIedical 
Inspector  upon  blanks  provided  for  the  purpose  of  each  case  inspected 
or  investigated.  Beginning  Oct.  15,  School  Medical  Inspectors  will 
vaccinate  free  of  charge  any  child  or  pupil  who  may  apply  to  them  for 
vaccination,  and  must  issue  a  certificate  of  vaccination  to  those  entitled 


254  Medical  Inspection  of  Schools 

to  the  same.  The  inspectors  will  vaccinate  no  child  without  the  con- 
sent of  parent  or  guardian. 

The  Department  prefers  that  the  family  physician  should  perform 
vaccination;  but  if  the  parent  or  guardian  of  a  child  wishes  it  done  by 
the  Department  the  child  may  be  taken  or  sent  to  the  School  Medical 
Inspector  or  Public  Vaccinator,  whose  duty  it  then  is  to  vaccinate 
such  child  and  furnish  a  certificate  without  charge. 

Examine  every  school  pupil's  arm  to  determine  the  vaccinal  status. 
Any  discovered  not  complying  with  the  vaccination  ordinance  must  be 
excluded  from  school  by  the  principal.  Read  the  ordinance  carefully 
and  be  governed  by  it  in  the  matter  of  vaccination.  Inspectors  must 
make  monthly  reports  upon  blanks  furnished  for  that  purpose,  giving 
the  number  of  tubes  of  vaccine  received  during  the  month,  the  number 
of  primary  vaccinations  performed,  the  number  of  re- vaccinations 
performed,  the  number  of  certificates  issued  to  those  previously  vaccin- 
ated within  seven  years  and  entitled  to  a  certificate  without  a  re-vac- 
cination, the  number  of  attempted  vaccinations  on  primary  subject 
resulting  in  failure  to  take,  and  the  number  of  attempts  at  vaccination 
in  previously  vaccinated  subject  resulting  in  failure  to  take. 

Inspectors  must  carry  with  them  a  supply  of  the  Department  circu- 
lars to  hand  out  for  instruction  in  cases  of  infectious  diseases.  The 
circulars  are :  Information  for  the  family  in  case  of  contagious  diseases. 
Circulars  on  prevention  of  consumption.  The  Vaccination  Creed. 
Special  circulars  on  each  of  the  infectious  diseases  and  warning  slips 
to  distribute  and  paste  up  for  the  pubHc  to  read.  Spatulas  for  tongue 
depressors.     Culture  mediums  and  outfits  for  Widal  test. 

Additional  Duties  of  School  Medical  Inspectors 
The  city  has  been  divided  into  eleven  districts.  A  Medical  Inspec- 
tor, a  Sanitary  Inspector  and  a  Milk  Inspector  is  placed  in  each  of  these 
districts.  Each  of  these  districts  is  subdivided  into  nine  districts  with 
a  School  Medical  Inspector  in  each  of  these  minor  districts.  The 
nine  School  Medical  Inspectors  will  be  under  the  direction  of  the  Medical 
Inspector.  Each  morning  before  9  o'clock  the  location  of  the  infectious 
diseases  reported  to  the  Department  will  be  telephoned  to  the  School 
Inspector  in  the  district  from  which  the  case  is  reported.  The  Medical 
Inspector  will  have  the  same  information  from  the  nine  districts.     The 


Rules  Issued  to  Medical  Inspectors  255 

School  Inspector  will  visit  all  cases  reported  from  his  district,  see  that 
proper  isolation  is  established,  determine  who  from  contiguous  flats  or 
houses  can  safely  remain  in  school,  and  see  that  the  warning  card  is  on 
the  door  or  where  it  will  best  serve  the  purpose  of  warning  any  who 
may  approach  the  infected  premises.  See  also  that  a  warning  card  is 
posted  where  the  milk  man  who  delivers  milk  will  see  it,  leave  the 
Department  circulars  gi%'ing  information  in  cases  of  contagious  diseases 
and  distribute  and  post  the  small  warning  leaflet  in  the  near-by  neigh- 
borhood and  mail  a  notification  card  to  the  principal  of  school. 

The  Inspector  notified  will  take  smears  in  cases  of  diphtheria  to 
determine  when  the  case  is  ready  for  termination.  When  the  District 
Medical  Inspector  has  more  antitoxin  work  than  he  can  attend  to,  the 
School  Medical  Inspector  will  aid  in  this  work.  When  the  School 
Inspector  is  in  doubt  about  a  diagnosis  he  will  call  upon  the  District 
Medical  Inspector  to  help  in  making  a  diagnosis.  The  School  Inspector 
is  to  have  charge  of  all  infectious  diseases  in  his  restricted  territory 
and  will  be  held  responsible  for  the  work  in  the  territory  assigned  him. 
The  Medical  Inspector  will  be  held  responsible  for  the  work  of  the  nine 
School  Inspectors  in  his  district.  To  assist  the  Medical  Inspectors  three 
diagnosticians  have  been  designated — one  on  each  of  the  three  sides 
of  the  city.  In  making  inspections  and  investigations  you  will  observe 
the  following  instructions: 

Inspectors  must  keep  in  close  touch  with  the  Department  of  Health 
so  they  may  be  reached  without  delay  when  wanted. 

Contagious  diseases  and  suspected  contagious  diseases  reported 
to  the  Department  of  Health  are  assigned  to  the  Medical  Inspectors 
and  School  Medical  Inspectors  either  for  inspection  or  investigation. 

Cases  for  inspection  are  those  reported  by  physicians.  In  these 
cases  see  that  the  family  receives  a  copy  of  the  Department  "Circular 
of  Information  Upon  the  Management  of  Contagious  Diseases,"  and 
give  them  such  further  advice  concerning  the  best  methods  to  pursue 
for  preventing  the  spread  of  contagion  as  you  deem  necessary. 

Especially  instruct  the  family  in  regard  to  the  length  of  time  cases 
should  be  isolated  and  impress  upon  them  the  necessity  of  a  thorough 
disinfection  after  the  case  has  terminated. 

Tell  them  to  have  their  doctor  notify  the  Department  when  the 
case  is  free  from  giving  off  contagion  and  the  house  is  ready  for  disin- 


256  Medical  Inspection  of  Schools 

fection — and  not  before.  Disinfectors  are  frequently  sent  to  families 
only  to  find  that  the  patient  is  still  in  the  contagious  stage,  especially 
in  scarlet  fever.     This  means  loss  of  time  to  the  disinfecting  force. 

Notify  by  postal  card  provided  the  principal  of  every  school  in  the 
vicinity,  both  public  and  parochial,  during  vacation  as  well  as  while 
school  is  in  session,  whom  to  exclude  from  school  and  take  such  other 
measures  in  the  case  as  may  be  needed  to  protect  the  public  health. 
You  are  the  judge  of  whom  it  is  safe  to  permit  to  attend  school  from 
flats  or  houses  contiguous  to  infected  premises. 

If  you  find  the  family  disregarding  the  doctor's  instructions  concern- 
ing isolation,  disinfection  of  excretions,  etc.,  supplement  his  instructions 
and  through  yomr  own  efforts  see  that  the  family  observes  proper  pre- 
cautions. 

If  the  case  is  in  any  way  connected  with  a  shop  or  store,  at  once 
make  the  case  safe  to  the  pubHc  by  one  of  the  following  plans: 

1.  When  it  is  best  to  do  so,  the  Department  of  Health  will  remove 
the  patient  to  a  hospital.  No  one  can  move  a  person  sick  with  an 
infectious  disease  without  the  consent  of  the  Commissioner  of  Health. 

2.  If  the  patient  remains,  the  room  must  be  shut  off  from  the  store 
by  sealing  cracks  of  doors  and  keyholes  with  paper  and  paste.  All 
communication  between  the  sickroom  and  the  store  must  be  stopped. 

3.  If  neither  of  the  above  plans  is  followed  the  store  must  be  closed, 
the  door  locked  and  the  public  excluded. 

Cases  for  investigation  are  supposed  cases,  such  as  are  reported 
to  the  Department  through  other  sources  than  physicians.  These  you 
will  visit  and  ascertain  the  nature  of  the  disease,  and  if  found  to  be 
scarlet  fever,  diphtheria,  whooping  cough  or  measles,  see  that  the 
attending  physician,  if  there  be  one,  reports  the  case  to  the  Department, 
or  report  it  yourself  by  card,  as  you  do  in  a  case  where  there  is  no  physi- 
cian. Put  up  a  warning  card  and  take  the  same  precautionary  measures 
as  in  cases  for  inspection. 

Send  notices  to  principals  of  schools  of  any  and  all  contagious 
diseases  encountered  while  inspecting  and  investigating  cases. 

Make  daily  reports  to  the  Department  of  all  cases  inspected  or 
investigated. 

Endeavor  to  learn  the  source  of  infection  in  every  case:  milk  sup- 
ply, fruit,  infected  clothing,  or  persons,  etc.,  and  communicate  to  the 


Rules  Issued  to  Medical  Inspectors  257 

Department  any  information  of  interest  which  you  may  learn  concern- 
ing this  subject. 

When  notified  of  a  suspected  case  of  smallpox  the  Inspector  must 
go  to  the  case  forthwith.  An  hour's  delay  may  result  in  many  needless 
exposures. 

The  following  suggestions  as  to  conduct  in  the  presence  of  smallpox 
should  be  observed  so  far  as  the  circumstances  of  the  case  will  permit 
with  safety.  The  Inspector  must  supply  any  deficiency  in  these  instruc- 
tions which  the  case  may  demand  for  the  safety  of  the  public. 

When  entering  a  house  where  there  is  a  suspected  case  of  contagious 
or  infectious  disease  do  not  remove  your  hat  or  overcoat;  keep  the 
overcoat  buttoned. 

Do  not  shake  hands  with  any  one  in  the  house.  Do  not  sit  down 
or  touch  anything  in  the  house  and  especially  avoid  touching  the  patient 
or  bed  clothing.  To  expose  the  patient  for  examination  call  upon  the 
patient  or  some  one  present  to  remove  the  clothing  for  you.  When 
leaving  the  house  have  some  one  open  the  door  so  as  to  avoid  touching 
any  infected  doorknob. 

Except  to  vaccinate  the  inmates  of  the  house,  it  is  not  necessary 
to  touch  anything  about  the  premises  except  the  floor  with  the  soles  of 
your  shoes. 

If  these  precautions  are  observed  there  is  no  danger  of  carrying  the 
disease  to  others. 

When  it  is  determined  the  case  is  one  of  smallpox,  fill  out  the  history 
blank  provided  for  the  purpose  (Form  2),  telephone  the  information 
to  the  Department  and  promptly  mail  the  filled  blank  to  the  Chief 
Medical  Inspector. 

Telephone  instructions  as  to  the  disposal  of  the  case,  whether  an 
ambulance  or  a  carriage  is  needed,  the  amount  of  disinfecting  to  be  done 
and  the  number  of  vaccinators  needed. 

In  filling  out  the  blank  secure  a  list  of  all  who  have  in  any  way  been 
exposed  to  the  contagion  since  the  first  day  of  the  sickness,  learn  if 
letters  or  laundry  have  been  sent  out  from  the  house  and  where  and  to 
whom  sent.     Give  the  vaccinal  status  of  those  exposed  so  far  as  you  can. 

It  is  the  duty  of  the  Inspector  to  vaccinate  or  see  that  some  other 
medical  inspector  vaccinates  all  who  are  known  to  be  exposed  to  the 
infection.     Do  not  leave  or  allow  this  duty  to  be  done  by  the  "  family 
17 


258  Medical  Inspection  of  Schools 

physician."  It  is  the  duty  also  of  the  Inspector  to  secure  the  consent 
of  the  patient  or  family  for  the  removal  of  the  patient  to  the  Isolation 
Hospital.     Do  not  leave  this  duty  to  the  ambulance  driver. 

Until  the  ambulance  comes  the  case  must  be  made  safe.  If  it  is 
necessary  to  police  the  house  to  secm-e  safety,  do  so.  After  securing 
the  prompt  vaccination  of  all  exposed  it  is  the  Inspector's  duty  to  see 
the  exposed  every  other  day  for  fifteen  to  twenty  days.  If  the  vaccina- 
tion does  not  take,  repeat  until  it  does  take. 

If  there  is  doubt  about  the  diagnosis,  vaccinate  the  inmates  of  the 
house,  make  the  case  safe  to  others  and  see  the  patient  later. 

A  Medical  Inspector  must  be  courteous  and  should  be  tactful  in  all 
his  relations  to  cases  of  smallpox,  the  same  as  a  doctor  should  be  in 
his  private  practice.  He  should  be  a  complete  master  of  the  situation, 
able  to  dispose  of  complications  and  duties  as  they  arise,  in  a  proper 
manner.  It  should  not  be  burdensome  to  do  so,  for  the  reward  is  always 
present,  the  consciousness  that  it  is  life-saving  work. 

Use  discretion  and  seciure  compliance  with  the  ordinance  without 
force. 

This  can  almost  always  be  done,  but  if  necessary  the  police  power 
can  be  used  to  enforce  compliance  with  the  law. 

II.    Instructions  to  Medical  Inspectors  of  Public  Schools 
Detroit,  Mich. 

1.  The  pupils  to  be  inspected  will  be  referred  to  the  inspectors  by 
the  principal  for  two  reasons : 

A.  Those  who  have  been  absent  one  or  more  days. 

B.  Those  in  the  school  whom  the  teacher  may  suspect  to  be 
;  suffering  from  communicable  diseases. 

These  two  classes  must  be  kept  separate  in  the  reports. 

2.  The  inspection  is  to  be  made  with  reference  to  communicable 
diseases  only,  and  pupils  are  to  be  excluded  for  the  following  diseases : 

Scarlet  Fever  Mumps  Pediculosis 

Diphtheria  Smallpox  Ringworm 

Tonsillitis  Chickenpox  Impetigo 

Rotheln  Whooping  cough  Scabies 


Rules  Issued  to  Medical  Inspectors  259 

or  other  communicable  diseases  of  the  skin  and  scalp,  and  communi- 
cable diseases  of  the  eye. 

3.  In  making  throat  examinations,  the  wooden  tongue  depressors 
supplied  must  be  used  to  the  exclusion  of  all  other  depressors.  Each 
tongue  depressor  must  be  used  only  once.  Aseptic  methods  must  be 
employed  in  all  examinations. 

4.  Whenever  a  child  is  excluded,  brief  but  suflficient  reason  therefor 
must  be  written  on  the  exclusion  card. 

5.  Medical  inspectors  will  use  their  own  judgment  about  the  accept- 
ance of  family  physician's  certificates.  You  have  the  right  to  ignore 
them  if  such  action  is  justified  by  your  personal  investigation  of  a  case  at 
school. 

6.  The  principal  excludes  children  from  school,  the  inspector 
recommends  to  the  principal  exclusions  when  justified,  the  principal 
acts  accordingly.  Do  your  utmost  to  maintain  harmony  and  coopera- 
tion with  principals. 

7.  Be  sure  and  give  exclusion  cards  in  every  instance,  so  parents 
will  be  notified 

8.  Remember  you  have  no  jurisdiction  as  inspector  beyond  the 
threshold  of  the  public  schools  of  your  district.  DO  NOT  examine 
pupils  at  your  office  or  any  place  outside  of  the  public  schools. 

9.  Use  great  discretion  in  examining  pupils.  Do  not  keep  them 
waiting  any  longer  than  necessary. 

10.  On  discovery  of  smallpox,  diphtheria,  or  scarlet  fever  cases 
notify  Health  Officer  AT  ONCE  by  telephone.  Blanks  for  reports, 
etc.,  can  always  be  obtained  at  the  Board  of  Health  Building,  233  St. 
Antoine  Street. 

11.  Report  promptly  to  Health  Officer  whenever  illness  or  accident 
prevents  you  from  going  to  your  work. 

12.  Send  in  your  weekly  reports  PROMPTLY. 

13.  Medical  inspectors  are  paid  on  the  fourth  Saturday  of  each 
month.     Checks  are  at  City  Hall,  office  of  City  Treasurer. 


26o  Medical  Inspection  of  Schools 

III.     Rules   for   the    Medical   Inspection   of  the  Public   School 
Children,  Health  Department,  Springfield,  Mass. 

Under  the  authority  of  the  revised  laws  of  the  State  of  Massachusetts, 
the  Board  of  Health  of  this  city  has  arranged  a  system  of  medical  in- 
spection of  pupils  attending  the  public  schools. 

The  objects  of  the  medical  inspection  of  school  children  are:  (i) 
Identification  of  all  pupils  requiring  medical  care.  (2)  Prompt  ex- 
clusion from  school  of  all  pupils  suffering  from  communicable  diseases. 
(3)  Detection  of  ailments  and  diseases  other  than  communicable 
diseases.  (4)  Detection  of  defects  of  sight  or  hearing  or  other  disability 
injurious  to  pupils. 

Under  the  law,  the  tests  of  sight  and  hearing  shall  be  made  by  the 
teachers,  and  the  necessary  rules  of  instruction,  test  cards,  etc.,  will  be 
distributed  as  soon  as  they  are  ready. 

It  is  desirable  that  the  Medical  Inspector  have  the  use  of  a  room  for 
the  examination  of  children.  The  Medical  Inspectors  will  visit  each 
school  twice  weekly,— Monday  and  Thursday  mornings.  The  Principal 
of  the  school  and  the  Medical  Inspector  should  agree  upon  the  hour  of 
inspection,  which  should,  as  far  as  possible,  serve  the  best  interests 
of  the  two  or  more  schools  to  which  the  inspectors  are  assigned.  The 
Medical  Inspector  will  examine  such  children  as  are  indicated  by  the 
teachers. 

The  following  described  children  should  be  sent  to  the  Inspector 
at  the  appointed  time: 

A.  Every  child  returning  to  school  without  a  certificate  from  the 

Board  of  Health  after  absence  on  account  of  illness,  or 
from  unknown  cause. 

B.  Every  child  who  shows  signs  of  being  in  ill  health,  or  suffering 

from  infectious  or  contagious  disease. 

C.  Every  child  returning  to  school  after  having  been  excluded  by 

the  Inspector. 

Children  showing  symptoms  of  the  following  diseases  are  to  be 
sent  home  immediately: 


Rules  Issued  to  Medical  Inspectors  261 

Smallpox  Diphtheria  Mumps 

Scarlet  Fever  Influenza  Scabies 

Measles  Tonsillitis  Trachoma 

Chickenpox  Whooping  Cough  Ringworm 

Tuberculosis  Pediculosis  Impetigo  contagiosa. 

In  case  exclusion  from  school  is  warranted,  the  exclusion  card  is 
to  be  filled  out  and  put  in  a  sealed  envelop  and  given  to  the  child  to  take 
home.  A  record  of  each  case  must  be  made  upon  the  card  provided 
for  the  purpose,  to  be  kept  by  the  rinpcipal,  and  upon  the  large  blank 
to  be  returned  to  the  Board  of  Health  at  the  end  of  each  week.  In  case 
any  of  the  above  mentioned  diseases  be  found,  the  Board  of  Health  is 
to  be  at  once  notified  on  blanks  provided  for  this  purpose. 

In  many  cases  of  exclusion,  children  should  be  allowed  to  return  to 
school  promptly  if  they  can  furnish  evidence  that  they  are  under  treat- 
ment for  the  disease  indicated.  In  this  way  many  children  suffering 
from  ailments  of  a  special  nature  will  be  permitted  to  attend  school 
instead  of  being  kept  out  of  their  classes. 

Swabs  should  be  taken  by  the  Inspector  from  all  suspicious  throats. 

Medical  Inspectors  (or  the  family  physician)  are  expected  to  vacci- 
nate such  children  as  require  it.  No  prescription  or  medical  treatment 
is  to  be  given  any  child  by  the  Medical  Inspector  while  in  the  perform- 
ance of  his  duties  except  as  follows : 

In  special  cases  prescriptions,  furnished  by  the  Health  Department, 
are  to  be  provided  free  of  charge  for  the  following  diseases:  Impetigo 
contagiosa,  ringworm,  scabies,  animal  parasites  in  the  hair. 

Rules  governing  the  admission  of  children  to  school  after  illness 
with  contagious  disease: 

School  children  may  return  to  school  after — 

Diphtheria  when  two  negative  cultures  have  been  obtained. 
Scarlet  fever  after  three  weeks,  or  when  peeling  has  ceased. 
Measles  when  catarrhal  symptoms  have  ceased. 
Whooping  cough  after  cough  has  stopped. 
Mumps  when  swelling  has  disappeared. 
Chickenpox  when  skin  is  free  from  crusts  and  scabs. 


262  Medical  Inspection  of  Schools 

During  the  continuance  of  diphtheria  and  scarlet  fever  in  the  house- 
hold, school  children  exposed  to  the  contagion  cannot  return  to  school. 

The  Medical  Inspector's  attention  should  be  called  to  any  of  the 
following  conditions: 

Skin  and  Hair 

A.  Animal  parasites  or  nits  in  the  hair. 

B.  Crusted  or  scaly  patches  or  sores  about  the  face,  neck,  or 

hands. 

C.  Crusts  in  the  scalp  or  loss  of  hair. 

D.  Scaling  about  the  fingers. 

E.  Pimples  in  the  spaces  between  the  fingers. 

F.  Swollen  glands. 

G.  Any  evidence  of  pronounced  itching  on  the  part  of  the  child. 

Eyes 

A.  Sensitiveness  to  light. 

B.  Redness  of  the  eyes. 

C.  Discharge  from  the  lids. 

D.  Crusted  condition  about  the  eyelashes. 

Ears 

Running  from  the  ears  and  crusty  patches  thereon. 

Children  who  are  slightly  hard  of  hearing  sit  with  their  mouths 
partially  open,  which  gives  them  a  somewhat  dull  expression.  They 
hear  questions  imperfectly,  hence  are  slow  and  often  stupid  in  their 
answers,  since  they  try  to  conceal  the  hardness  of  hearing. 


Index 


Adenoids — 

Effect  on  pupils  of 15 

Study  of,  in  Philadelphia 189 

Data  concerning,   in  New  York 
City...  192,  193,  195,  196,  197,  199 

Aix-la-Chapelle — 

Salaries  of  school  inspectors  in. .    144 

Alabama — 

Inquiries   regarding  medical   in- 
spection unanswered  in 182 

Albany,  N.  Y.— 

Medical  inspection  in 26 

List  of  symptoms  of  disease  fur- 
nished to  teachers  in 55 

Albany  County  Medical  Society — 

Medical  inspection  conducted  by     26 

Allen,  Dr.  William  H.— 

Quotation  from 16 

Allport,  Dr.  Frank- 
Quotation  from 106 

Instructions  prepared  by 129 

America — 

Salaries  of  school  physicians  in i 

Comprehensive  systems  rare  in..     82 

American  School  Hygiene  Asso- 
ciation— 
Second  Congress  of 159 

Ann  Arbor,  Mich. — 

Medical  inspection  in 26 

Dr.  Elliott  Kent  Herdman,  medi- 
cal inspector  of 53 

Card  of  notification  to  parents. .     96 

Antwerp — 

Development  of  medical  inspec- 
tion in 19 

Argentine  Republic — 

Medical  inspection  in i 

Scope  of  medical  inspection  in..      23 


Arizona — 

Inquiries  regarding   medical   in- 
spection unanswered 182 

Arkansas — 

Inquiries  regarding  medical    in- 
spection unanswered 182 

Asbury  Park,  N.  J. — 

Medical  inspection  in 26 

Teacher's   request    to    inspector, 

card 59 

Quotation   from    Superintendent 

of  Schools 154 

Associated  Charities — 

Of  Minneapolis,  Minn 26 

Associated   Charities   and  Wo- 
men's Club — 

Medical  inspection  conducted  by, 
in  Minneapolis,  Minn 26 

Atlantic  City,  N.  J.— 

Medical  inspection  in 26 

Congress    of    American    School 
Hygiene  Association  in 159 

Attendance,  Average — 

In  seventeen  cities 140 

In  Springfield,  Mass 146 

In  Montclair,  N.  J 146 

Austria — 

Development  of  medical  inspec- 
tion in 20 


Backward  Children — 

Study  of  problems  of 14 

Discussion  concerning 185,  186 

Investigation       concerning,       in 

Camden,  N.  J 190 

Investigation  concerning,  in  New 

York  City 192 

Conclusions  regarding 201 


263 


264 


Index 


Baltimore,  Md. — 

Medical  inspection  in 26 

School  nurses  in 67 

Dr.  H.  W.  Buckler,  medical  in- 
spector in 72 

Weekly  report  of  nurse  in 79 

Medical    inspection    under    city 
ordinances 172 

Barmen,  Dr.  JohnH. — 

Appointed      school       physician, 
Lawrence,  Mass 155 

Bayonne,  N.  J. — 

Defective  vision  in  schools  of  . .  .82,  83 

Belgium — 

Medical  inspection  in i 

Development  of  medical  inspec- 
tion in 19 

Blake,  Dr.  Clarence  J. — 

Opinion  signed  by 105 

Blauvelt,  Dr.  A.— 

Appointed  Chief  Medical  Inspec- 
tor in  New  York  City 24 

Boas,  Dr.  Franz — 

Work  of,  in  Toronto  and  Wor- 
cester, Mass 6 

Boston- 
Work  of  Dr.  H.  P.  Bowditch  in . .  6 
Population  of  foreign  parentage 

in .--- -..- 7 

First  medical  inspection  in 24 

Children  referred  to  medical  in- 
spectors in S3 

School  nurses  in 67 

Department  of  School  Hygiene  in  73 
Facts  concerning  medical  inspec- 
tion in 140 

Salary  of  nurses  in 143 

Extract  from  report  of  Superin- 
tendent of  Schools  of 153 

Medical  inspection  begun 168 

Bowditch,  Dr.  H,  P.— 

Work  of,  in  Boston 6 

Breathing,  Defective — 

Data    concerning,    among    New 
York  City  children 

192,  193,  195,  196,  197,  199 

British  Board  of  Education — 
Quotation    from    Memorandum 

of I,  21,  168,  184 

Reference  to  Memorandum  of . .    160 


Brockton,  Mass. — 

Exclusion  card  used  in 30 

Monthly   report   of   medical    in- 
spector      31 

Examinations  and  exclusions  in.     49 
Facts  concerning  medical  inspec- 
tion in 1 40 

Brussels — 

Development  of  medical  inspec- 
tion in 19 

Bryan,  Dr.  James  E. — 

Investigation  conducted  by 190 

Buckler,  Dr.  H.  W.— 

Medical  inspector  of  Baltimore.     72 

Buffalo,  N.  Y.— 

Medical  inspection  in 26 

Bulgaria — 

Medical  inspection  in i 

Bureau    of    Education,    United 
States- 
Bulletin  of 188 


Cairo,  Egypt — 

Salaries  of  school  physicians  in. .      23 

California — 

Eyesight  and  hearing  tests  by 
State  Board  of  Health 25 

Legal  status  of  medical  inspec- 
tion in 176 

Camden,  N.  J. — 

Medical  inspection  in 26 

Defective  vision  in  schools  of —     83 
Facts  concerning  medical  inspec- 
tion in 140 

Reference  to  school  conditions  in  188 
Investigation  by  Superintendent 
of  Schools  in 190 

Chart— 

Of  teeth,  used  in  Northampton, 
Mass 97 

Pray  Astigmatic 106 

Snellen iii,  129,  130 

For  testing  vision,  Connecticut 
State  Board  of  Education 

122,  123,  124,  125 

Chelsea,  Mass. — 

Facts  concerning  medical  inspec- 
tion in 1 40 


Index 


265 


Chicago — 

Population  of  foreign  parentage 
in 7 

First  medical  inspection  in 24 

System  of  inspectors'  reports  in.     41 

Exclusion  notice 42 

Envelope  report  of  medical  in- 
spector      43 

Number    of    medical    inspectors 

employed  in 138 

Medical  inspection  begun 168 

Legal  status  of  medical  inspec- 
tion in 1 74 

Chicopee,  Mass. — 

Results  of  physical  examinations 
in 88 

Children  per  Inspector — 

In  seventeen  cities 140 

ChUe— 

Development  of  medical  inspec- 
tion in 23 

Cincinnati,  O. — 

Medical  inspection  in 26 

Cleveland,  O. — 

Work  of  George  W.  Ehler  in 6 

Population  of  foreign  parentage 

in 7 

Medical  inspection  in 26 

Defective  vision  in  schools  of 82,  83 

Reference  to  report  of  Superin- 
tendent of  Schools  of 102 

Free  eyeglasses  in 148 

Extract  from  report  of  Superin- 
tendent of  Schools 153 

Code  Card — 

New  York  City 36 

Colorado — 

Legal  status  of  medical  inspec- 
tion in 176 

Connecticut — 

Medical  inspection  law i 

Law  concerning  testing  of  eye- 
sight  25,  104 

Reference  to  medical  inspection 
law 137 

Legal  status  of  medical  inspec- 
tion in 176 

Contagious  Diseases — 

Excluded  in  New  York  City. ...     33 


Postal  card  of  notification  con- 
cerning      43 

For  which  pupils  are  excluded  in 
various  cities 48 

Rules  for,  in  Providence,  R.  I.. .     56 

Cornell,  Dr.  Walter  S.— 

Quotations  from 66,  76,  102 

Work  of,  in  Philadelphia 77 

Reference  to  studies  by 189 

Cornman,  Dr.  O.  P. — 

Reference  to  article  by 188 

Craps — 

Game  of 10 


Cronin,  Dr.  John  J. — 

Work  of,  in  New  York  City  ... .  6 

Quotation  from 66 

Opinion  of 143 


Dallas,  Texas — 

Medical  inspection  in 26 

Dayton,  O. — 

Medical  inspection  in 26 

Defective  Hearing — 

In  various  school  systems 83 

Defective  Vision — 

Problem  of  pupil  with 15 

In  various  school  systems 83 

Data  concerning   in   New   York 
City  ...192,  193,  195,  196,  197,  199 

Defects,  Physical — 

Decrease  with  age 2,  199 

Reported  in  Massachusetts 49 

Not  discovered  by  teachers 81 

Delaware — 

Inquiries   regarding  medical    in- 
spection unanswered 182 

Dental  School  of  Harvard  Uni- 
versity— 

New  Bedford  leaflet  endorsed  by     98 

Dental  School  of  Tufts  College- 
New  Bedford  leaflet  endorsed  by     98 

Des  Moines,  Iowa — 

Medical  inspection  in 26 

Detroit,  Mich. — 

Medical  inspection  in 26,  1 79 

Diseases  for  which  pupils  are  ex- 
cluded in 48 


266 


Index 


Detroit,  Mich. — Cont'd. 

System  of  sending  pupils  to  in- 
spectors in 52 

Facts  concerning  medical  inspec- 
tion in 140 

Diseases — 

Reported  in  Massachusetts 49 

Dispensary — 

Founded  in  Havre,  France 19 

District  of  Columhia — 

Legal  status  of  medical  inspec- 
tion in 174 

Dresden — 

Development  of  medical  inspec- 
tion in 19 

Dunfermline,  Scotland — 

Data  on  defective  teeth  of  chil- 
dren in 97 

Defective  vision  in  schools  of 83 

Durgin,  Dr.  Samuel  H. — 

Opinion  of 50 

E's— 

Direction  for  using  chart  of 115 

Chart  of 125 

East  Sussex,  England — 

Cost  of  medical  inspection  in...    147 

Edinburgh — 

Defective  vision  in  schools  of .     83 

Edison,  Dr.  Cyrus — 

Sanitary  Superintendent,  New 
York  City 24 

Egypt- 
Salaries  of  school  physicians  in. .     23 

Ehler,  George  W.— 

Work  of,  in  Cleveland,  0 6 

Elgin,  111.— 

Medical  inspection  in 26 

England — 

Medical  inspection  in i 

Salaries  of  school  physicians  in . .  i 

Feeding  of  school  children 16 

Society  of  Medical   Officers  for 

Schools 22 

Payment  of  school  physicians  ac- 
cording to  work  done 144 

Medical  inspection  act 159 


Englewood,  N.  J. — 

Medical  inspection  in 26 

Epidemics — 

Closing  of  public  schools  during     12 

Evansville,  Ind. — 

Medical  inspection  in 26 

Everett,  Mass. — 

Combined    directions    and    pre- 
scriptions  44,  45,  46 

Examinations — 

And  exclusions  in  five  cities 49 

Exclusion  Card — 

Brockton,  Mass 30 

New  York  City 35 

Chicago 42 

Exclusions — 

Inspector's  daily  report  of.  New 

York  City 38 

In  five  cities 49 

In  Haverhill,  Mass.,  and  Newark, 

N.J 150 

In    Massachusetts   and    in   New 

York  City 151 

Eyeglasses — 

By  whom  furnished 147 

Given  away  in  Cleveland,  O 148 

Furnished    at   $1.00    in    Lowell, 

Mass 148 

Furnished  at  cost  price  in  Phila- 
delphia     148 

Eyesight — 

Problem  of  pupil  with  defective.     15 
(See  also  Vision) 

Eyesight  and  Hearing  Tests — 

Under  state  boards  of  health 25 

(See  also  Vision) 


Falkner,  Dr.  Roland  P.— 

Reference  to  article  by 188 

Florida — 

Legal  status  of  medical  inspection  177 

Foreign  Parentage — 

Population  of,  in  various  Amer- 
ican cities 7 

Fort  Dodge,  Iowa — 

Medical  inspection  in 26 


Index 


267 


Fort  Worth,  Texas- 
Medical  inspection  in 26 

Fourth  Section,  Philadelphia — 

Work  in  schools  of 69 

Work  of  trained  nurse  in 70 

France — 

Medical  inspection  in i 

Feeding  of  school  children  in 16 

Development  of  medical  inspec- 
tion in 18 

Society  of  Medical  Inspectors  of 

Schools 22 

La  Medecine  Scolaire 22 


Galveston,  Texas — 

Medical  inspection  in 26 

Georgia — 

Legal  status  of  medical  inspec- 
tion in 177 

Germany — 

Development  of  medical  inspec- 
tion in 19 

Care  of  teeth  of  children  in 97 

Salaries  of  school  physicians  ac- 
cording to  work  done 144 

Glands,  Enlarged — 

Data    concerning,    among    New 
York  City  children 

192,  193,  195,  196,  197,  199 

Grand  Rapids,  Mich. — 

Medical  inspection  in 26 

Dr.  C.  Koon  of 52 

School  nurses  in 67 

Greece — 

Golden  Age  of 8 

Guildford,  England — 

Salaries  of  inspectors  in 142 


Hackensack,  N.  J. — 

Medical  inspection  in 26 

Half  Time- 
Discussion  concerning 185,  186 

Conclusions  concerning 187,  201 

Harrington,  Dr.  Thomas  F. — 

Quotation  from 53,  66,  152 


Harrisburg,  Pa. — 

Medical  inspection  in 26 

Quotation  from  Report  of  School 

Nurses 103 

Reference    to    report    to    School 

Board  of 141 

Hartford,  Conn, — 

Medical  inspection  in 26 

Harvard  College,  Dental  School 
of— 

New  Bedford  leaflet  endorsed  by     98 

Haskin,  Frederick  J. — 

Extract  from  article  by 23 

Haverhill,  Mass. — 

Exclusions  in 150 

Extract  from  report  of  Superin- 
tendent of  Schools 156 

Havre,  France — 

Free  public  dispensary ig 

Hazleton,  Pa. — 

Medical  inspection  in 26 

Hearing  Tests — 

Time  of 2 

In  Massachusetts 109 

Report  of,  in  Massachusetts no 

Record  of,  in  Massachusetts 112 

By  New  York  State  Department 

of  Health 113,  116 

Report  of  teacher  on \  . .    119 

By  State  Board  of  Health,  Utah. .    129 
Report  on,  Utah 131,  132,  133 

Herdman,  Dr.  Elliott  Kent- 
Quotation  from 54 

Houston,  Texas — 

Medical  inspection  in 26 

Association     of     Opticians     and 
Aurists 26 

Hungarian — 

Children,  statement  concerning  .    103 

Htmgary — 

Development  of  medical  inspec- 
tion in 20 

Hypertrophied  Tonsils — 

Effect  on  pupils  of 15 

Data    concerning,    among    New 
York  City  children 

192,  193>  195.  196,  197.  199 


268 


Index 


Idaho — 

Legal  status  of  medical  inspec- 
tion in 177 

Illinois — 

Per  cent,  of  urban  population  in       6 
Leg;;!  status  of  medical  inspec- 
tion in 1 74 

Index  Card — 

New  York  City 37 

Indiana — 

Legal  status  of  medical  inspec- 
tion     176 

Iowa — 

Inquiries  regarding  medical   in- 
spection unanswered 182 

Italian — 

Directions  printed  in 40,  46 

Japan — 

Medical  inspection  in i,  23 

Jersey  City,  N.  J.— 

Medical  inspection  in 26 

Juvenal — 

Quotation  from 12 

Kansas — 

Legal  status  of  medical  inspec- 
tion in 178 

Kentucky — 

Legal  status  of  medical  inspec- 
tion in 178 

Knowles,  Dr.  William  F.— 

Opinion  signed  by 105 

Koon,  Dr.  C— 

Quotation  from 52 

Lancet,  The — 

Advertisements  in 142 

Lansing,  Mich. — 

Medical  inspection  in 26 

Dr.  Burt  Nottingham  of 52,  53 

Lawrence,  Mass. — 

Examinations  and  exclusions  in .     49 
Facts  concerning  medical  inspec- 
tion in 140 

Conflict  between  Board  of  Health 
and  Board  of  Education 155 


Laws  on  Medical  Inspection — 

Connecticut i,  25,  104,  137,  176 

English 159 

Massachusetts 

I,  16,  25,  104,  137,  159,  162 

New  Jersey i,  16,  25,  171 

New  York 166 

Vermont i,  25,  137,  181 

Leaflets — 

On  care  of  teeth,  New  Bedford, 
Mass 98 

On  care  of  teeth,  Waltham,  Mass.     99 

Lederle,  Dr.  Ernest  J. — 

Quotation  from 66 

Leipsic — 

Development  of  medical  inspec- 
tion in 19 

Salaries  of  school  inspectors  in. .    144 

Leslie,  Prof.  George  L. — 

Quotation  from 94,  106 

Lice — 

(See  Pediculosis) 


44 


Liege,  Belgium — 

Development  of  medical  inspec- 
tion in 19 

Lincoln,  Neb. — 

Medical  inspection  in 26 

Littleton,  Mass. — 

Salary  of  school  physician  in 141 

Lockstep — 

In  physical  matters 13 

In  promotions 188 

London — 

Children  referred  to  medical  in- 
spectors in 53 

School  nurses  in 66 

Long  Beach,  Cal. — 

Medical  inspection  in 26 

Los  Angeles,  Cal. — 

Medical  inspection  in 26 

Superintendent  of  Schools,  E.  C. 

Moore,  of 52,  53 

School  nurses  in 67 

Physical  examinations  in 89,  139 

Louisiana — 

No  medical  inspection  laws  in 182 


-i; 


Index 


269 


Louvain,  Belgium — 

Development  of  medical  inspec- 
tion in 19 

Lowell,  Mass. — 

Eyeglasses  furnished  at  uniform 
price  in 148 


Maddoz — 

Multiplex  Rod 106 

Maine — 

No  medical  inspection  laws  in..    182 

Mannheim,  Germany — 

Salaries  of  school  inspectors  in. .    144 

Martin,  George  H. — 

Quotation  from 157 

Maryland — 

Extract    from    code    of    public 
health  laws  in 172 

Massachusetts — 

Medical  inspection  in i 

Medical  inspection  law  in...i,  16,  25 
Extent  of  medical  inspection  in  25,  27 

School  membership  in 49 

Diseases  and  defects  reported  in     49 
Pamphlet  issued  by  State  Board 

of  Education 54 

Defective  vision  in  schools  of 83 

Medical  Society  of 106 

Reference  to  medical  inspection 

law  in 104,  159 

Extract  from  medical  inspection 

law  in 137 

Exclusions  in 151 

Medical  inspection  law  quoted  in 

full 162 

Maxwell,  Dr.  William  H.— 

Quotation  from 151 

Measles — 

Statistics     concerning     mortality 
from,  in  Munich 50 

Medical     Academy    of     Dental 
Science — 

New  Bedford  leaflet  endorsed  by     98 

Medical  Inspector — 

Monthly    report    of,     Brockton, 

Mass 31 

Teacher's  request  to,  Providence, 

RI 59 


Teacher's    request     to,     Asbury 

Park,  N.J 59 

Teacher's  request  to,  Washing- 
ton, D.  C 60,  61 

Teacher's  request  to,  Somerville, 

Mass 62 

Number  of,  in  seventeen  cities..  140 

Children  per,  in  seventeen  cities.  140 

Salaries  of,  in  seventeen  cities —  140 

Medical  Journal,  New  York — 

Reference  to  article  in iSg 

Medical    Society    of    Pennsyl- 
vania— 
Paper  read  before 69 

Michigan — 

Conference  of  health  officers  in . .     54 
Legal  status  of  medical  inspec- 
tion in 178 

Milwaukee,  Wis. — 

Population  of  foreign  parentage 

in 7 

Medical  inspection  in 26 

Medical  Society 26 

Defective  vision  in  schools  of ... .  83 

Minneapolis,  Minn. — 

Medical  inspection  in 26,  179 

Associated  Charities  and  Wo- 
men's Club 26 

Defective  vision  in  schools  of  —     83 
Physical  examinations  in 87 

Minnesota — 

Legal  status  of  medical  inspec- 
tion in 179 

Mississippi — 

No  medical  inspection  laws  in  . .   182 

Missouri — 

No  medical  inspection  laws  in..    182 

Montana — 

No  medical  inspection  laws  in  . .    182 

Montclair,  N.  J. — 

Medical  inspection  in 26 

Examinations  and  exclusions  in.     49 
Facts  concerning  medical  inspec- 
tion in 140 

Cost  of  medical  inspection  in...    146 

Montgomery    County     Medical 
Society — 
Medical  inspection  conducted  by     26 


2/0 


Index 


Monthly  Report — 

Of  medical  inspector,  Brockton, 
Mass 31 

Moore,  E.  C. — 

Reference  to 52 

Quotation  from 53 

Morse,  Dr.  Moreau — 

Appointed  Medical  Inspector  of 
Schools,  New  York  City 24 

Moscow — 

Medical  inspection  in 21 

Mount  Holly,  N.  J  — 

Medical  inspection  in 26 

Munich — 

Statistics     concerning     mortality 
from  measles  in 50 


National   Educational  Associa- 
tion— 

Extract  from  address  delivered 
before  Department  of  Super- 
intendence of  the 53 

Nebraska — 

Legal  status  of  medical  inspec- 
tion in 1 79 

Nevada — 

No  medical  inspection  laws  in..    182 

Newark,  N.  J. — 

Medical  inspection  in 26 

Diseases  for  which  pupils  are  ex- 
cluded in 48 

Examinations  and  exclusions  in.     49 
Facts  concerning  medical  inspec- 
tion in 140 

Exclusions  in 150 

Extract  from  report  of  Superin- 
tendent of  Schools 153 

Statement  of  Superintendent  of 
Schools  of 171 

New  Bedford,  Mass. — 

Leaflet  on  care  of  teeth  in 98 

New  Hampshire — 

Legal  status  of  medical  inspection 
in 179 

New  Haven,  Conn. — 

Medical  inspection  in 26 

School  nurses  in 67 


Facts  concerning  medical  inspec- 
tion in 140 

New  Jersey — 

Medical  inspection  law  in 

I,  16,  25,  171 

Newmayer,  Dr.  S.  W. — 

Quotation  from 58,  66 

Card  used  by,  in  Philadelphia..     63 
Reference  to  paper  by 69 

New  Mexico — 

Inquiries  regarding  medical   in- 
spection unanswered 182 

New  Orleans,  La. — 

Medical  inspection  in 27 

Newport,  R.  I. — 

Medical  inspection  in 26 

Newton,  Mass. — 

Quotation   from    Superintendent 
of  Schools loi 

New  York  City- 
Work  of  Dr.  John  J.  Cronin  in. .       6 
Population  of  foreign  parentage 

in 7 

First  medical  inspection  in 24 

Medical  inspection  in 27 

Description  of  system  in 30 

Diseases  for  which  pupils  are  ex- 
cluded in 48 

Salaries  of  nurses  in 66,  143 

Corps  of  nurses  established  in..     67 

Duties  of  school  nurse  in 74 

Defective  vision  in  schools  of 83 

Physical  examinations  in 85,  87 

Quotation   from   Superintendent 

of  Schools  of 102,  151 

Physical  examinations  in 139 

Facts  concerning  medical  inspec- 
tion in 140 

Exclusions  in 151 

Account  of  medical  inspection  in  169 
Physical  defects  of  children  in..    188 

Investigation  conducted  in 191 

Physical  examination  by  Board 
of  Health  of 198 

New  York  State— 

Per  cent,  of  urban  population  in.       6 
Eyesight    and    hearing   tests    by 

State  Board  of  Health  in 25 

Examinations  conducted  by  De- 
partment of  Health  in 104 


Index 


271 


New  York  State — Cont'd. 

Law  concerning  children  in  insti- 
tutions in 166 

Norristown,  Pa. — 

Medical  inspection  in 27 

Northampton,  England — 

Salaries  of  inspectors  in 142 

Northampton,  Mass. — 

Teeth  chart  used  in 97 

North  Carolina — 

Inquiries   regarding  medical   in- 
spection unanswered 182 

North  Cumberland,  England — 

Salaries  of  inspectors  in 142 

North  Dakota- 
No  medical  inspection  laws  in. . .    182 

Norway — 

Development  of  medical  inspec- 
tion in 20 

Nose  and  Throat  Defects — 

Data  concerning 189 

Nottingham,  Dr.  Burt — 

Reference  to  opinion  of 52 

Quotation  from 53 

Nurses- 
Appointment  of,   in  New  York 

City- 32 

Work  of,  in  Fourth  Section,  Phil- 
adelphia   70 

Visits  to  homes 71 

Work  of,  in  New  York  City 74 

Weekly  report  of,  Philadelphia.  78 

Weekly  report  of,  Baltimore .  79 

Quotation  from  report  of 103 


Ogden,  Utah- 
Medical  inspection  in 27 

Teacher's  report  to  principal  in.  133 

Card  of  warning  to  parents  in 133 

Excuse  for  absence  of  pupil  in  . .  134 

Ohio- 
Percent,  of  urban  population  in.       6 
Legal  status  of  medical  inspection 
in 180 

Oklahoma — 

Legal  status  of  medical  inspection 
in 180 


Ophthalmologist — 

In  Philadelphia 148 

Orange,  N.  J. — 

Medical  inspection  in 27 

School  nurses  in 67 

Oregon — 

Legal  status  of  medical  inspection 
in 180 

Osier,  Prof.  William- 
Quotation  from 141 


Parents — 

Notice  to,  New  York  City 86 

Notice  to,  Somerville,  Mass 96 

Notice  to,  .\nn  Arbor,  Mich 96 

Notice  to,  Massachusetts 113 

Paris — 

Development  of  medical  inspec- 
tion in 18 

Part  Time — 

Discussion  concerning 185,  186 

Conclusions  concerning 187,  20  j 

Pasadena,  Cal. — 

Medical  inspection  in 27 

Physical  examinations  in 89 

Passaic,  N.  J. — 

Medical  inspection  in 27 

Paterson,  N.  J. — 

Medical  inspection  in 27 

Facts  concerning  medical  inspec- 
tion in 140 

Pawtucket,  R.  I. — 

Defective  vision  in  schools  of 83 

Pediculosis — 

Directions  for,  Everett,  Mass..  .44,  45 
Mention     of     card     concerning, 

Utica,  N.  Y 46 

Pupils  excluded  for,  in  five  cities  48 
Pupils  excluded  for,  in  New  York 

City 69,  74 

Proportion  of  exclusions  for 151 

Pennsylvania — 

Hospitals 76 

No  medical  inspection  legislation 

in 173 

Per  Capita  Cost — 

Of  medical  inspection  in  .\merica       i 


272 


Ind 


ex 


Per  Capita  Cost— Cont'd. 

Of  inspection  for  detection  of  con- 
tagious diseases 2 

Of  physical  examinations 2 

For  salaries  in  seventeen  cities  . .  140 

In  twenty-four  cities 141 

Pericles — 

The  Age  of 8 

Philadelphia — 

Resolution  of  Bureau  of  Health 

of 24 

Medical  inspection  in 27 

Diseases  for  which  pupils  are  ex- 
cluded in 48 

Dr.  Newmayer  of 58 

Card  used  by  Dr.  Newmayer 63 

School  nurses  in 67 

Report    of    work    of    nurses    in 

schools  of  Fourth  Section  of . .  70 

Visits  of  nurse  to  homes  in 71 

Card    recommending    pupil    for 

treatment  in 77 

Weekly  report  of  nurse  in 78 

City  ophthalmologist  of 148 

Medical  inspection  begun  in 168 

Legal  status  of  medical  inspec- 
tion in 173 

Physical  Defects — 

Decrease  with  age 2,  199 

Per  cent,  attended  to  by  parents.  10 1 

Physical  Examinations — 

Per  capita  cost  of 2 

In  New  York  City 85 

In  Minneapolis  and  in  New  York 

City 87 

In  Sioux  City,  Iowa 88 

In  Chicopee,  Mass 88 

In  Los  Angeles,  Cal 89 

In  Pasadena,  Cal 89 

Physical  Record  Cards — 

Pasadena,  Cal 90 

Los  Angeles,  Cal 92 

Utica,  N.  Y 94 

Asbury  Park,  N.  J 95 

Pinard,  Prof. — 

Use  of  term  "puericulture"  by. .  22 

Mainfield,  N.  J.— 

Medical  inspection  in 27 

Play- 
Changed  conditions  of 9 


Polk  County   Medical  Associa- 
tion— 

Medical  inspection  conducted  by     26 

Port  Chester,  N.  Y.— 

Medical  inspection  in 27 

Porter,  Dr.  Eugene  H. — 

New  York  State  Board  of  Health 
instructions  signed  by 117 

Porter,  Dr.  William  H.— 

Work  of,  in  St.  Louis,  Mo 6 

Portland,  Oregon — 

Medical  inspection  in 27,  180 

Pray — 

Astigmatic  Charts 106 

Providence,  R.  I. — 

Medical  inspection  in 27 

Printed  material  used  in 40 

Rules  for  contagious  diseases  in.  56 

Rules  distributed  to  pupils  in 57 

Teacher's  request  to  inspector. .  59 

Psychological  Clinic — 

Reference  to  publication  of 188 

Reference  to  article  in 189 

Reading,  Pa. — 

Medical  inspection  in 27 

Rebuck,  Dr.  C.  S.— 

Medical  inspection  by,  in  Harris- 
burg,  Pa 26 

Record  Cards — 

Individual,  New  York  City 84 

Giving  teacher's  comment,  Pasa- 
dena, Cal 90 

Physical,  Los  Angeles,  Cal 92,  93 

Physical,  Utica,  N.  Y 94 

Physical,  Asbury  Park,  N.  J.  . . .  95 
Sight  and  hearing  tests,  Massa- 
chusetts   112 

Reports — 

Monthly,    of   medical    inspector, 

Brockton,  Mass 31 

Inspector's  daily,   of  exclusions, 

New  York  City 38,  39 

Envelope,  daily,  Chicago,  111.  ...     43 
Weeklv,  of  nurse,   Philadelphia, 

Pa..' 78 

Weekly,  of  nurse,  Baltimore,  Md.     79 
Of    sight    and    hearing,    Massa- 
chusetts     1 10 


Index 


273 


Reports— Cont'd. 

Of  teacher,  New  York  State.  .118,  1 19 

Of  teacher,  Connecticut 127,  128 

To  State  Board  of  Health,  Utah    132 
Of  teacher  to  principal,  Ogden, 
Utah 133 

Retarded  Children — 

Study  of  problems  of 14 

Discussion  concerning 185,  186 

Investigation    concerning,    Cam- 
den, N.  J 190 

Investigation    concerning.     New 

York  City 192 

Conclusions  regarding 201 

Rhode  Island — 

Per  cent,  of  urban  population  in.       6 
Legal  status  of  medical   inspec- 
tion in 181 

Rochester,  N.  Y. — 

Medical  inspection  in 27 

Roumania — 

Development  of  medical  inspec- 
tion in 21 


Salaries — 

Of  school  physicians  in  America 

and  in  England i 

Of  medical  inspectors  in  Cairo, 

Eg>-pt 23 

Of  medical  inspectors  in  seven- 
teen cities 140 

Of  school  physicians  in  Shelburne 
and  Littleton,  Mass 141 

Of  medical  inspectors  in  England  142 

Of  school  nurses  in  New  York 
and  Boston 143 

Of  school  nurses  in  New  Haven, 
Conn 144 

Of  medical  inspectors  in  Wies- 
baden, Germany 144 

Of  medical  inspectors  in  Leipsic, 
Aix-la-Chapelle,  and  Mann- 
heim, Germany 144 

Salt  Lake  City,  Utah- 
Medical  inspection  in 27 

San  Antonio,  Texas — 

Medical  inspection  in 27 

San  Francisco,  Cal. — 

Population  of  foreign  parentage 

in 7 

18 


Opinion  of  Deputy  Superinten- 
dent of  Schools 176 

Schamberg,  Dr. — 

Reference  to 76 

Schenectady,  N.  Y. — 

Medical  inspection  in 27 

School    Hygiene,     Department 
of— 
Boston 73 

Schubert,  Dr.  Paul- 
Quotation  from 144 

Seattle,  Wash.— 

Medical  inspection  in 27 

Facts  concerning  medical  inspec- 
tion in 140 

Shelburne,  Mass. — 

Salary  of  school  physician  in. . . .    141 

Shepherd,  Dr.  Fred  S.— 

Quotations  from 154 

Sioux  City,  Iowa — 

Medical  inspection  in 27 

Physical  examinations  in 88 

Snellen — 

Test  types 106 

Chart Ill 

Directions  for  using  chart ...  129,  130 

Society — 

Of  Medical  Officers  for  Schools . .     22 
Of  Medical  Inspectors  of  Schools     22 

Medical,  of  Pennsylvania 69 

Visiting  Nurse,  of  Philadelphia. .     69 
Medical,  of  Massachusetts 106 

Somerville,  Mass. — 

Card  of  statement  of  physician 
and  teacher  in 62 

Card  of  notification  of  parents  in     96 

Quotation  from  Superintendent 
of  Schools  of loi 

Facts  concerning  medical  inspec- 
tion in 140 

South  Carolina — 

Legal  status  of  medical  inspec- 
tion in 181 

South  Dakota — 

No  medical  inspection  laws  in  —    182 

Springfield,  Mass. — 

Examinations  and  exclusions  in.     49 


Teeth- 
Chart    used     in     Northampton, 

Mass 97 

Care  of,  in  Germany 97 

Data    from    Dunfermline,    Scot- 
land      97 

Leaflet  on  care  of.  New  Bedford, 

Mass 98 

Leaflet    on    care    of,    Waltham, 
Mass 99 


274  Index 

Springfield,  Mass. — Cont'd. 

P'acts  concerning  medical  inspec- 
tion in 140 

Cost  of  medical  inspection  in 146 

Quotation  from  report  of  School 
Board  of 156 

Standish,  Dr.  Myles — 

Opinion  of 105 

Stanley,  Annie  L, — 

Work  of,  in  Philadelphia 69 

Stewart,  Dr.  HackwortH — 

Quotation  from 161 

St.  John,  Dr.  S.  B.— 

Instructions  prepared  by 121 

St.  Joseph,  Mo. — 

Medical  inspection  in 27 

St.  Louis,  Mo. — 

Work  of  Dr.  William  H.  Porter  in       6 
Medical  inspection  in 27 

Suffolk  County,  Mass. — 

Defective  vision  in  schools  of 83 

Superior,  Wis. — 

Medical  inspection  in 27 

Sweden — 

Medical  inspection  in i 

Development  of  medical  inspec- 
tion in 21 

Switzerland — 

Medical  inspection  in i 

Development  of  medical  inspec- 
tion in 21 

Syracuse,  N.  Y. — 

Medical  inspection  in 27 

Description  of  record  card  used  in  46 

Directions  furnished  teachers  in.  56 

School  nurses  in 67 


Defective,  data  concerning, 
among  New  York  City  chil- 
dren... 192,  193,  195,  196,  197,  199 

Tennessee — 

Inquiries  regarding  medical  in- 
spection unanswered 182 

Texas — 

Legal  status  of  medical  inspec- 
tion in 181 

Thorndike,  Dr.  Edward  L.— 

Reference  to  publication  of 188 

Time— 

Of  vision  and  hearing  tests 2 

Of  physical  examinations 2 

Of  examinations  as  basis  for  re- 
muneration     143 

Tonsils — 

Enlarged,  efi'ect  on  pupils 15 

Enlarged,  study  of,  in  Phila- 
delphia    189 

Enlarged,  data  concerning, 
among  New  York  City  chil- 
dren... 192,  193,  195,  196,  197,  199 

Toronto — 

Work  of  Dr.  Franz  Boas  in 6 

Tufts  College,  Dental  Sthool  of— 

New  Bedford  leaflet  endorsed  by     98 


Union  Hill,  N.  J.— 

Medical  inspection  in 27 

United  States — 

First  rriedical  inspection  in 24 

Cities  of,  having  medical  inspec- 
tion      26 

Urban  Population — 

Change  in 6 

Percentage  of,  in  various  states  . .       6 

Utah- 
Eyesight  and  hearing  tests  under 

State  Board  of  Health  of 25 

Examinations  conducted  by  State 

Board  of  Health  of 104 

Legal  status  of  medical   inspec- 
tion in 181 

Utica,  N.  Y.— 

Description  of  record  card  used 

in 46 

Defective  vision  in  schools  of 83 


Index 


275 


Vandiver,  Almuth  C. — 

Reference  to  paper  by 159 

Vermont — 

Medical  inspection  law  in i 

Reference  to  medical  inspection 

law 25,137 

Legal  status  of  medical  inspec- 
tion in 181 

Virginia — 

Inquiries  regarding   medical    in- 
spection unanswered 182 

Vision  and  Hearing  Tests — 

Time  of 2 

By  school  teachers,  opinions  con- 
cerning   105 

In  Massachusetts 107 

Report  of no,  118,  127,  132,  133 

Snellen's  chart  for in 

Record  of 112 

By  New  York  State  Department 

of  Health 113 

By    State    Board   of   Education, 

Connecticut 120 

Charts  used  in 122,  123,  124,  125 

By  State  Board  of  Health,  Utah  129 

Vision,  Defective — 

In  various  school  systems 83 

Data  concerning,   in  New  York 
City 192,  193,  195,  196,  197,  199 

Visiting  Nurse  Association — 

Of  Harrisburg,  Pa 26 

Visiting  Nurses'  Society — 

Of  Philadelphia 69 


Wadsworth,  Dr.  O.  F.— 

Opinion  of 106 

Walker,  Dr.  D.  Harold- 
Opinion  signed  by 105 

Waltham,  Mass. — 

Diseases  for  which  pupils  are  ex- 
cluded      48 

Attention  to  children's  teeth  in . .     98 
Leaflet  on  care  of  teeth 99 

Washington,  D.  C— 

Medical  inspection  in 27 

Meeting  of  Department,  National 
Educational  Association  in 53 


Teacher's  request  to  inspector.  60,     61 

Washington  State — 

Legal  status  of  medical  inspec- 
tion in 182 

Waterbury,  Conn.— 

Medical  inspection  in 27 

Waverly,  R,  I.— 

Medical  inspection  in 27 

Webster,  R.H.— 

Opinion  of 176 

Wells,  Dr.  David  W.— 

Quotation  from 106 

j  Westchester,  N.  Y.— 

Medical  inspection  in 27 

West  Riding  District,  England — 
Salaries  of  inspectors  in 142 

West  Virginia — 

Inquiries  regarding  medical   in- 
spection    182 

White  Plains,  N.  Y.— 

Medical  inspection  in 27 

Directions  furnished  teachers  in.     56 

Wiesbaden,  Germany — 

Method  of  medical  inspection 19 

Salaries  of  school  inspectors  in. .    144 

Wilkes-Barre,  Pa.— 

Printed  rules  distributed  to  pupils     5  7 

Williams,  Dr.  Charles  H.— 

Opinion  of 106 

Wilmington,  Del. — 

Medical  inspection  in 27 

Reference  to  study  of  school  con- 
ditions in 188 

Wisconsin — 

Legal  status  of  medical  inspection 
in 182 

Witmer,  Dr.  Lightner — 

Founder  of  Psychological  Clinic.   188 

Women's  Club — 

Of  Minneapolis,  Minn 26 

Woonsocket,  R.  I. — 

Medical  inspection  in 27 


276 


Index 


Woonsocket,  R.  I. — Cont'd. 
Facts  concerning  medical  inspec- 
tion in 140 

Worcester,  Mass. — 

Work  of  Dr.  Franz  Boas  in 6 

Defective  vision  in  schools  of 83 

Facts  concerning  medical  inspec- 
tion in 140 


"Wyoming — 

Inquiries   regarding  medical   in- 
spection unanswered 182 

Yiddish- 
Directions  printed  in 40 

Yonkers,  N.  Y.— 

School  nurses  in 67 


^.v^v-pL      il 


HQ 


This  book  is  DUE  on  the  last  date  stamped  below 


'  Am  ^   ^^^^ 
OCT    a  i93a 

3UN  191948 

m  1  '^  ^^^^ ' 


MM  0  1  1989 


Form  L-9-15)?;-ll,"^7 


:i^1 


r«T 


3411 
G95in 


(rUllCk." 


Medical 


inspection  of 
schools. 


•^-li:A. 


;ptI^6  192& 


> 


UCLA-Voung  Research   Library 

LB3411    .G95nn 

y 


L  009   532  694   8 


